Hari itu, Sabtu tanggal 26 Januari 2013 Pukul 13.20 WIB.

Aku yang baru pulang Dinas dari Padang Panjang selama 1 bulan akhirnya tiba di Bukittinggi tempat dimana aku Kuliah. Saat itu aku bersama mama dan papa yang menjemput dan mengantarkanku ke Bukittinggi.
Setibanya di Kost,,
hhmm. . .  lho.! kok ada cowo sich dsni?? cakepp juga sich.. hah..! sama cewe juga.! hhm.. mungkin Suami istri kali yaa..?!.
" heiii. . . . Dian udah pulang Dinass yee? " sapa kakak kostku.
" haha... iyaa nich kak, udah berakhir.! kembali kuliah lagi..." jawabku sambil cengir.
" haaaa.... kak Dian udah datang.! asyikkk bisa main lagi...! Sambung Naufal (anak kakak kost ) sambil berlari menghampiri dan memelukku..
" ahaha... iyaa, tapi kakak balek Solok dulu yaach, udah kangen rumah soalnya.! jawabku.
" yeee. . truss kapan kesini lagi kak?? Naufal kan udah lama gak main2 sm kakak.. jawabnya memelas.
" Besok siang kak balek kesini, sekarang cuma nganterin barang2 ajja. oya, ada penghuni kost baru ya Fal?  tanyaku tiba2.
" iyaa... kamar kakak yg lama udah ada yg ngisi, kakak sich pake pindah kamar segala.." jawabnya sambil terus memelukku.
" Kok yg ngisinya cowo sm cewe Fal ? tanyaku lagi..
" yee..kakak, itu mah sekeluarga yg ngisi.. yg berdua itu ade kakak.. gimana sich? emang gak keliatan apa miripnya?! " jawabnya sambil tertawa.
"owhh . . . kirain........?! hahaha... " tawaku.
" yaa udah.. kakak OTW Solok yaa... mama papa kakak dah nungguin tuh.. bye Naufal.. besok dech kita cerita2.. Ok ". sambil melepaskan pelukkan Naufal dan berlari ke mobil..
" okk kak.. banyak lho yg mau aku ceritain k kakak. Bye ". jawabya sambil melambaikan tangan..
" Ok.. next time yaaa... jawabku.

To Be Continued.

Sebenarnya ini hanya sekedar iseng. Daripada nggak ada yg di pake buat ngisi waktu luang mendingan cari tahu nama Korea, China, atau Jepang kamu ^^. Saya sudah buatkan bagaimana mencarinya dengan cara yg sederhana, yaitu melalui tanggal lahir kamu. Anggap saja ini sebuah games, dan ini sama sekali tidak digunakan di Korea, China, mau pun Jepang. Yap, mulai saja. Perhatikan ketentuan nya dengan baik ^_^.

MENCARI NAMA

Korea - China - Jepang

- Korean ::
Nama di urutkan dari angka terkahir Tahun, Bulan, dan Tanggal kelahiran.
Jika tanggal lahir anda 12 Februari 1993.
Maka, 5 - 2 - 1993.
Angka terakhir tahun kelahiran 3, bulan 2, dan tanggal 5.
Jadi nama Korea anda: "Kim Ji Kyo"

- Chinesee ::
Caranya masih sama dengan mencari nama Korea.
Jika anda lahir pada 17 Agustus 1945.
Maka, 17 - 8 - 1945.
Urutkan dengan ketentuan angka terakhir Tahun Kelahiran, kemudian bulan, dan diakhiri Tanggal Lahir.
Jadi 5 = Lim, 8 = Nan, dan 17 = Ping.
Nama China anda: "Lim Nan Ping"

- Japan ::
Berbeda dengan cara sebelumnya.
Ketentuannya, Nama pertama di ambil dari angka terakhir tahun kelahiran.
Sedangkan nama Kedua merupakan gabungan dari Tanggal dan bulan kelahiran.
Pada bulan kelahiran terdapat tanda pemisah "~".
Tanda ini digunakan untuk memisahkan nama cewek dan cowok.
ini dia, NamaCewek~NamaCowok.
Sebab dalam penamaan Jepang biasanya hanya menggunakan dua suku kata, dan boleh di bolak-balik.
Contohnya, 8 Oktober 1991 = 8 - 10 - 1991.
Jika di ikuti urutannya, 1 [angka terkahir dari 1991] - 8 [tanggal lahir] + 10 [bulan kelahiran].
Maka, nama untuk cewek menjadi: "Momo Kagesuki" atau "Kagesuki Momo" [boleh di bolak balik]
dan untuk nama cowok menjadi: "Momo Kageraku" atau "Kageraku Momo" [boleh di bolak balik]

:: Tahun Kelahiran

XXX0    |- Park |- Huang |- Sakurai

XXX1    |- Song |- Choi  |- Momo

XXX2    |- Kim  |- Lee   |- Hideyashu

XXX3    |- Choi |- Wen   |- Kugou

XXX4    |- Shin |- Lim   |- Ginichi

XXX5    |- Kang |- Qie   |- Zen

XXX6    |- Han  |- Zhang |- Koukei

XXX7    |- Lee  |- Liu   |- Shikaku

XXX8    |- Sung |- Xian  |- Komozaku

XXX9    |- Jung |- Ma    |- Shinji

:: Bulan Kelahiran

01    |- Yong   |- Zi    |- rinko~kun

02    |- Ji     |- Kong  |- ki~tora

03    |- Gyn    |- Gin   |- mira~ko

04    |- Hye    |- Ma    |- ri~masa

05    |- Dong   |- Chao  |- miki~rou

06    |- Sang   |- Han   |- mi~tou

07    |- Ha     |- Mei   |- ringo~koda

08    |- Hyo    |- Nan   |- ka~yori

09    |- Soo    |- Sun   |- mori~da

10    |- Eun    |- You   |- suki~raku

11    |- Hyu    |- Hou   |- mika~ka

12    |- Rae    |- Rin   |- yuki~jin

:: Tanggal Kelahiran

01    |- Hwa    |- Lian  |- Mitsu

02    |- Woo    |- Xun   |- Kou

03    |- Joon   |- Man   |- Mina

04    |- Hee    |- Choi  |- Ikki

05    |- Kyo    |- Ming  |- Sudo

06    |- Kyung  |- Yao   |- Zen

07    |- Wook   |- Quan  |- Shika

08    |- Jin    |- Lian  |- Kage

09    |- Jae    |- Yi    |- Kaze

10    |- Hoon   |- Ge    |- Kimi

11    |- Ra     |- Zhuo  |- Gaka

12    |- Bin    |- Ren   |- Shu

13    |- Sun    |- Lie   |- Hi

14    |- Ri     |- Yu    |- Kumo

15    |- Soo    |- Jian  |- Shimi

16    |- Rim    |- Wei   |- Haru

17    |- Ah     |- Ping  |- Koda

18    |- Ae     |- Zhong |- Shon

19    |- Neul   |- Liang |- Yama

20    |- Mun    |- Bei   |- Bon

21    |- In     |- Yuan  |- Uzu

22    |- Mi     |- Dun   |- Shin

23    |- Ki     |- Zhang |- Yumi

24    |- Koo    |- Kou   |- Gyn

25    |- Byung  |- Mei   |- Shige

26    |- Seok   |- Ran   |- Ran

27    |- Gun    |- Chi   |- Shou

28    |- Yoo    |- Dong  |- Geru

29    |- Suk    |- Shin  |- Neko

30    |- Won    |- Kwok  |- Janko

31    |- Sub    |- Ren   |- To

Sahabat adalah naungan sejuk keteduhan hati dan Api unggun kehangatan jiwa, 

karena akan dihampiri kala hati gersang kelaparan,

dan dicari saat jiwa mendamba kedamaian

 

Sahabat kan mengisi kekuranganmu bukan mengisi kekosonganmu.

Sahabat adalah pemenuhan kebutuhan jiwa

 

Dialah ladang hati, 

yang ditaburi dengan kasih dan dituai dengan penuh rasa terima kasih.

Ketika ia menyampaikan pendapat, kalbu tak kuasa menghadang dengan bisikan kata “tidak”, 

dan tak pernah khawatir untuk menyembunyikan kata “ya”.

Bilamana dia terdiam tanpa kata,

hati senantiasa mencari rahasianya.

Dalam persahabatan yang tanpa kata, 

segala fikiran, hasrat, dan keinginan terangkum bersama, menyimpan keutuhan 

dengan kegembiraan tiada terkirakan.

 

Ketika tiba saat perpisahan,

janganlah ada duka,

sebab yang paling kau kasihi dalam dirinya, mungkin akan nampak lebih cemerlang dari kejauhan.

Seperti gunung yang nampak lebih agung dari padang dan ngarai.

Lenyapkan maksud lain dari persahabatan kecuali saling memperkaya roh kejiwaan.

Karena cinta berpamrih yang mencari sesuatu di luar jangkauan misterinya.

Dalam manisnya persahabatan,
biarkanlah ada tawa kegirangan.

pengen punya email Gmail dan Blog..
ne langkah2 nya :
1. pertama2 kalian harus log in dulu k akun goggle, kemudian pilih create akun atau buat akun
2. masukkan semua data2 kalian di kolom pengisian pendaftran akun tersebut
3. setelah semuanya lengkap lalu pilih create akun.

naahhh . . . . seperti ini nii...:
1. Langkah paling awal, siapkan koneksi internet, bukan browser, saya sarankan untuk menggunakan browser Chrome, karena lebih enak dan cepat menurut saya. Tapi kalau belum download, pakai dulu seadanya. bisa pake Internet Explorer atau Mozila Firefox
2. Masukan alamatnya urulnya http://mail.google.com/ atau  http://gmail.com . Sehingga tampil gambar seperti di bawah ini. Kemudian pilih tombol [create an account] atau Buat Akun yang berada di pojok kanan atas

3. Lalu masukan identitas kamu pada formulir pendaftaran, untuk langkah-langkah pengisian sangat mudah sekali, tidak jauh berbeda dengan cara pengisian pada layanan email di Yahoo.com. Perhatikan contoh pengisiannya di bawah ini.

4. Pendaftara pada akun gmail lebih ketat dari akun yahoo, sehingga kamu harus melakukan verifikasi nomor ponsel. Caranya tinggal masukkan nomor ponsel kamu pada  Kolom nomor telepon seperti gambar di bawah ini.

5.  Setelah masukkan nomor ponsel, silahkan cek kotak sms yang ada di ponsel kamu. kamu akan mendapatkan sms kode verifikasi dari google seperti gambar di bawah ini.

6. Masukkan kode dalam sms tersebut ke dalam kotak kode verifikasi yang telah ditampilkan seperti gambar di bawah ini. Kemudian klik tombol Verifikasi

7. Jika kode verifikasi yang kamu masukkan benar, kamu akan di bawa ke halaman selanjutnya, seperti gambar di bawah ini. Di halaman ini Kamu boleh mengupload Foto profil, atau langsung klik pada tombol  langkah berikutnya.

8.  Setelah melewati tahap di atas, kamu telah berhasil membuat email.  Untuk langkah berikutnya, silahkan klik tombol  Lanjut Ke Gmail.

9.  Nah, seperti inilah tampilan antar muka Dashboard Gmail kamu.  Di dalam sini kamu bisa menulis email, mengirim email, menerima email, dan juga membaca email.  Selain itu kamu juga bisa chating langsung dengan teman kamu yang juga pengguna gmail.

kemudian Cara Bikin Blog :
Untuk selanjutnya silahkan ikuti langkah-langkah cara membuat blog lengkap di berikut ini :
1. Untuk memulai mendaftar blog di blogspot silahkan kunjungi alamat situs  www.blogger.com, setelah itu cari tombol Sign up (daftar) yang ada di pojok kanan atas, seperti gambar di bawah ini

2. Setelah tombol sign up diklik, nanti akan muncul aplikasi pendaftaran pembuatan akun gooogle, seperti gambar di bawah ini. Silahkan lengkapi aplikasi tersebut. Gambar di bawah ini merupakan contoh pengisiannya.
Penjelasan pengisian : pada bagian Name, Isi nama  depan dan nama belakang kamu.
Pada Choose your username,  isi sesuai dengan keinginanmu, username ini nantinya berfungsi sebagai email login untuk akses ke dashboard blogspot kamu dan bisa juga untuk login ke Gmail. (jika username tidak tersedia, tambahka angka atau huruf di belakangnya),
Pada Create a Password, isi password kamu (gunakan yang mudah diingat), pada Confirm your password silahkan isi dengan password yang sama dengan password pada kolom pada create a possword tadi.
Pada birth day isi tanggal lahir kamu.  Pada Phone, isi dengan nomor ponsel kamu, untuk Curent your email, dikosongkan saja.  Pada type the two pieces of text, ketikan dua buah teks kode yang ada di atasnya.  Selanjutnya beri tanda centang pada dua kotak kecil di bawahnya, dan yang terakhir Klik pada tombol Next step.

3. Setelah kamu klik pada tombol next, akan ditampilkan perintah verifikasi akun, silahkan masukan nomor ponsel kamu. Kemudian klik tombool Send Verifikation Code. Nanti kamu akan mendapat sms dari google yang berisi  kode aktifasi.

4.  SMS kode verifikasi dari google ke ponsel kamu akan tampak seperti gambar di bawah ini.

5.  Masukkan kode verikasi sms di atas pada kolom yang tampil, seperti gambar di bawah ini. kemudian klik tombol Verify

6.  Jika langkah sebelumnya berhasil, kamu akan menjumpai halaman seperti gambar di bawah ini. Untuk menambahkan foto silahkan klik add profile photo,  jika ingin langsung ke langkah selanjutnya silahkan klik tombol Next Step.

7.   Selanjutnya akan tampil halaman seperti gambar di bawah ini. Ini merupakan tanda bahwa kamu telah memiliki sebuah akun google  berupa alamat email yang bisa digunakan untuk login ke Gmail.com dan blogger.com, selanjutnya silahkan klik tombol Back to blogger.

8. Jika melihat halaman seperti gambar di bawah ini abaikan saja , biar lebih cepat dalam membuat blog. SIlahkan klik tombol lanjutkan ke blogger.

9.   Setelah itu kamu akan masuk ke halaman utama Dashboard blogger. Di dashboard ini kamu bisa membuat blog, menulis posting, mengatur tema dan lain-lain.  Untuk membuat blog pertama kali klik tombol Blog Baru.

10.  Setelah tombol blog baru diklik, akan muncul  jendela pembuatan blog.  Pada bagian Judul isi  Judul blog kamu, pada bagian Alamat isi dengana alamat blog yang kamu inginkan. Pada template, pilih salah satu template yang kamu inginkan.  Kemudian klik tombol buat blog

11. Setelah langkah-langkah di atas, blog kamu sudah berhasil di buat.  Untuk menulis posting silahkan klik tombol Pensil, sedangkan untuk melihat tampilan blog yang masuk kosong (belum ada artikelnya) silahkan klik tombol lihat blog.


selamattt mencobaa yaaa.......

Abstraks.

Postnatal growth failure in preterm infants is due to interactions between genetic and environmental factors, which are not fully understood. We assessed dietary supply of nutrients in very-low-birth-weight (VLBW, < 1500 g) infants fed fortified human milk, and examined the association between nutrient intake, medical factors and growth during hospitalisation lasting on average 70 d. We studied 127 VLBW infants during the early neonatal period. Data were obtained from medical records on nutrient intake, growth and growth-related factors. Extra-uterine growth restriction was defined as body weight < 10th percentile of the predicted value at discharge. Using logistic regression, we evaluated nutrient intake and other relevant factors associated with extra-uterine growth restriction in the subgroup of VLBW infants with adequate weight for gestational age at birth. The proportion of growth restriction was 33 % at birth and increased to 58 % at discharge from hospital. Recommended values for energy intake (>500 kJ/kg per d) and intra-uterine growth rate (15 g/kg per d) were not met, neither in the period from birth to 28 weeks post-conceptional age (PCA), nor from 37 weeks PCA to discharge. Factors negatively associated with growth restriction were energy intake (Ptrend = 0·002), non-Caucasian ethnicity (P = 0·04) and weight/predicted birth weight at birth (Ptrend = 0·004). Extra-uterine growth restriction is common in VLBW infants fed primarily fortified human milk. Currently recommended energy and nutrient intake for growing preterm infants was not achieved. Reduced energy supply and non-Caucasian ethnicity were risk factors for growth restriction at discharge from hospital. [PUBLICATION ABSTRACT]

Postnatal growth failure in preterm infants is due to interactions between genetic and environmental factors, which are not fully understood. We assessed dietary supply of nutrients in very-low-birth-weight (VLBW, < 1500 g) infants fed fortified human milk, and examined the association between nutrient intake, medical factors and growth during hospitalisation lasting on average 70 d. We studied 127 VLBW infants during the early neonatal period. Data were obtained from medical records on nutrient intake, growth and growth-related factors. Extra-uterine growth restriction was defined as body weight < 10th percentile of the predicted value at discharge. Using logistic regression, we evaluated nutrient intake and other relevant factors associated with extra-uterine growth restriction in the subgroup of VLBW infants with adequate weight for gestational age at birth. The proportion of growth restriction was 33 % at birth and increased to 58 % at discharge from hospital. Recommended values for energy intake (>500 kJ/kg per d) and intra-uterine growth rate (15 g/kg per d) were not met, neither in the period from birth to 28 weeks post-conceptional age (PCA), nor from 37 weeks PCA to discharge. Factors negatively associated with growth restriction were energy intake (Ptrend = 0·002), non-Caucasian ethnicity (P = 0·04) and weight/predicted birth weight at birth (Ptrend = 0·004). Extra-uterine growth restriction is common in VLBW infants fed primarily fortified human milk. Currently recommended energy and nutrient intake for growing preterm infants was not achieved. Reduced energy supply and non-Caucasian ethnicity were risk factors for growth restriction at discharge from hospital. [PUBLICATION ABSTRACT]

Anda meminta layanan mesin penerjemahan "on-the-fly" untuk materi yang Anda pilih dari basis data kami. Fungsionalitas ini diberikan untuk kemudahan semata dan tidak dimaksudkan untuk mengganti terjemahan manusia. Tampilkan penafian lengkap

Baik ProQuest maupun para pemberi lisensinya tidak memberikan pernyataan atau jaminan apa pun terkait terjemahan tersebut. Terjemahan ini dihasilkan secara otomatis "SEBAGAIMANA ADANYA" dan "SEBAGAIMANA TERSEDIA" dan tidak disimpan dalam sistem kami. PROQUEST DAN PARA PEMBERI LISENSINYA SECARA KHUSUS MENAFIKAN SETIAP DAN SEMUA JAMINAN BAIK TERSURAT MAUPUN TERSIRAT, TERMASUK TANPA PEMBATASAN, SEGALA JAMINAN ATAS KETERSEDIAAN, AKURASI, AKTUALITAS, KELENGKAPAN, KEPATUHAN, KETERJUALAN, ATAU KECOCOKAN UNTUK TUJUAN TERTENTU. Penggunaan Anda atas terjemahan ini tunduk pada semua pembatasan penggunaan yang termuat dalam Perjanjian Lisensi Produk Elektronik dan dengan menggunakan fungsionalitas terjemahan ini Anda setuju untuk melepas setiap dan semua klaim terhadap ProQuest atau para pemberi lisensinya terkait penggunaan Anda atas fungsionalitas penerjemahan ini dan setiap keluaran yang diperoleh darinya. Sembunyikan penafian lengkap Penerjemahan diberdayakan oleh LEC.

Penerjemahan diberdayakan oleh LEC.

(ProQuest: ... denotes non-US-ASCII text omitted.)

Human and Clinical Nutrition

Abbreviations: ELBW, extremely low birth weight; PCA, post-conceptional age; VLBW, very low birth weight

Adequate nutrition during infancy and early childhood is important for normal human development. The period from mid-pregnancy to the age of 2 years is characterised by rapid growth and development of the central nervous system. The immediate consequences of inadequate perinatal nutritional supply include increased morbidity, suboptimal growth and delayed mental and motor development ⁽¹⁾. In the long term, early nutritional deficits are linked to impairments of intellectual performance, reduced work capacity and elevated risk for CHD and the metabolic syndrome⁽¹⁾.

Preterm infants have high nutrient requirements because they have missed the last trimester placental transfer of nutrients, and have therefore very small energy and nutrient reserves. Feeding problems are frequent, and most infants need parenteral feeding. Due to improved survival rate of very-low birth weight (VLBW; birth weight < 1500 g) infants, the nutritional challenges of these infants have received increasing attention ⁽²⁾.

Human milk is the preferred source of enteral feeding. In the Nordic countries, this milk is unpasteurised, and comes either from the mother or from a human milk donor⁽³⁾. Human milk feeding has several advantages compared with formula feeding. In addition to nutrients, human milk contains components with a positive effect on tolerance of enteral feeding. Moreover, feeding with human milk is associated with fewer infections, reduced frequency of necrotising enterocolitis, shorter stay in hospital and better psychomotor development as compared with other feeding regimens ^(4-6). However, human milk does not contain enough energy and essential nutrients to meet the very high requirements in VLBW infants, and preterm infants fed human milk apparently have a slower growth rate than formula-fed infants⁽⁷⁾. Fortification of human milk with energy, protein and minerals is associated with better weight gain, and improved length and head growth⁽⁸⁾. However, the optimal supply of energy and specific nutrients to this vulnerable group has not been established. Hence future research should be directed toward evaluating both short- and long-term outcomes in search of the optimal composition of fortifiers to preterm infants ⁽⁸⁾.

Growth restriction in preterm infants indicates that the nutrient requirements have not been adequately met, and there is a potential for improving the supply of macro- as well as micronutrients. On the other hand, too much energy may increase fat accumulation instead of lean body mass and thus potentially increase the risk of CHD later in life ⁽⁹⁾. Given this fine balance where too low as well as too high supply might be harmful, it is crucial to determine the optimal nutrient intake for these infants. The aim of the nutrition therapy of VLBW infants is to approximate intra-uterine growth and development ⁽¹⁰⁾. Studies from both USA and Western Europe have shown that this is seldom achieved and that many preterm infants are small for gestational age when they are discharged from hospital⁽¹¹⁾. It is not known whether this is the case also for infants receiving fortified human milk.

Thus, the aim of the present study was to assess nutrient intake and growth in VLBW infants fed primarily fortified human milk during hospitalisation, and to examine the association between nutrient intake and growth development during hospitalisation. Such knowledge is required before further improvement of feeding protocols can be made.

Methods

Subjects

Out of 217 VLBW infants consecutively born between December 2003 and October 2005 at four different hospitals (Rikshospitalet University Hospital, Akershus University Hospital, Buskerud Hospital and Vestfold Hospital) in Norway, 136 infants were eligible for the study. Exclusion criteria were major congenital abnormalities, cerebral haemorrhage (grade 3 or 4) as determined by ultrasound examination, death or parental denial of enrolment. Fifty-nine infants did not meet the inclusion criteria, and twenty-two parents refused to participate. Of the 136 infants included in the study, two died, three were excluded because of complications with major influence on their food intake and one infant was diagnosed with Down's syndrome. Three medical records were not available at the time of data collection, and these infants were also excluded. Thus, 127 infants are included in our analyses. The study was a part of an intervention study concerning the effect of long-chain PUFA on cognitive development in childhood, where the infants received a supplement of either a 50:50 mixture of n-3 and n-6 fatty acid or an equal amount of vegetable oil⁽¹²⁾. The present study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human patients were approved by the Regional Ethics Committee in Norway. Written informed consent was obtained from the parents.

Growth

Data about weight gain and head circumference were taken from the medical records. All infants were routinely weighed by the nursing staff every day or every second day. The scales had an accuracy of at least ± 5 g. Length was measured at birth and weekly until discharge at two of the hospitals. All nurses were trained on standard measurement techniques. Growth restriction at birth and discharge was defined as weight < the 10th percentile for post-conceptional age (PCA) according to updated Norwegian growth charts for fetal growth ⁽¹³⁾. Adequate weight for age at birth and discharge was defined as weight >10th percentile for PCA. PCA was based on routine ultrasound examination, conducted at approximately 18 weeks of gestation.

Nutrient intake

Dietary intake among VLBW infants during the neonatal period was estimated from daily records of the actual intake of parenteral nutrition, human milk and formulas during the hospital stay. Nutrient intakes from supplements were also included. The daily nutrient intake of each infant was calculated using a computer program and food database (developed at the Department of Nutrition, University of Oslo, Norway). Data on commercially available products for preterm infants were obtained from the manufacturers and added to the database. Data on nutrient content in human milk were obtained from Saarela et al.⁽¹⁴⁾, using different values for preterm milk (294 kJ, 3·8 g fat and 1·5 g protein per 100 ml) and donor milk (261 kJ, 3·2 g fat and 1·1 g protein per 100 ml). Energy intake is expressed in kJ (1 kcal = 4·18 kJ).

All infants received fortified human milk, either from their own mother or from a donor. Minimal enteral feeding with human milk was started as soon as possible, on the first or second day of life. The amount of parenteral feeding was reduced as the intake of human milk gradually increased. When the infants achieved an enteral intake of about 120 ml/kg, the human milk was fortified with energy (30 kJ/100 ml), proteins (0·8 g/100 ml) and minerals (Presemp; Semper AB, Stockholm, Sweden; or Enfamil Human Milk Fortifier; Mead Johnson, Evansville, IN, USA). The two fortifiers are quite similar in energy and protein content, but the Presemp fortifier does not include vitamins. Thus, infants receiving Presemp were given oral vitamin supplement (Multibionta; Trophen Merck, Darmstadt, Germany) containing 12·5 [mu]g vitamin D, 750 [mu]g vitamin A (retinyl palmitate) and 2 mg vitamin E ([alpha]-tocopherol). Infants in need of parenteral nutrition additionally received 1-4 ml/kg per d of a mixture containing fat-soluble vitamins (Vitalipid Infant; Fresenius Kabi, Oslo, Norway) and water-soluble vitamins (Soluvit; Fresenius Kabi). Infants treated with antibiotics routinely received 0·5 mg vitamin K ₁ every third day. Most VLBW infants received one additional daily dose of vitamin E (up to15 mg) from birth to 32 weeks PCA. At discharge, 76 % of the infants received only human milk. The remaining infants received different combinations of formulas and human milk. Food intake of breast-fed infants was calculated by weighing the infants before and after each meal. Infants receiving human donor milk during hospitalisation changed to term formula during the last days before discharge, at the mean age of 70 d.

Statistics

Data are presented as mean values and standard deviations and groups are compared by a t test when normal distribution was met. Non-normally distributed data are presented as medians with interquartile ranges (25 and 75 percentiles) and groups are compared by the Mann-Whitney test. Categorical data are presented as percentages or actual numbers, and groups are compared by the [chi] ² test.

The infants were categorised into two groups according to growth status at discharge: growth-restricted infants (n 74) and infants with adequate weight (n 53). Observations were further categorised into four groups based on PCA of the infants: < 28 weeks, 29-32 weeks, 33-36 weeks and >37 weeks age.

To study the energy and nutrient intake in relation to growth restriction at discharge, we used a linear mixed model for repeated measures (mixed model procedure in SPSS; SPSS Inc., Chicago, IL, USA). The covariance structure was a first-order autoregressive structure with heterogeneous variances.

In the subgroup of infants who were adequate weight for age at birth, the association between nutrient intake and growth restriction at discharge was examined by logistic regression analyses. Results are presented as OR with 95 % CI. Nutrient intake was categorised into tertiles. Test for trend across tertiles of variables was performed by treating the tertiles as continuous variables in the logistic regression analysis. Dietary intakes of protein, fat and Ca were highly correlated to energy intake (Pearson's r: 0·65 < or = r < or = 0·95) and these nutrients were energy adjusted by the residual method⁽¹⁵⁾. Total energy intake was included in the multiple regression models for nutrients.

In the final model for nutrient intake, adjustments were made for weight ratio at birth (actual weight/50th percentile weight for gestational age at birth) and ethnicity. Additional adjustments for gestational age, respiratory support, length of hospitalisation and sex did not change the results. All statistical analyses were performed with SPSS (version 14.0; SPSS Inc.) and a 5 % level of significance was used.

Because our present study was part of a larger study, the power calculations were performed on the basis of the Ages and Stages Questionnaire as the main endpoint. We estimated that sixty-three participants in each group would be satisfactory to have 80 % power for detecting a difference at the 5 % significance level of 21 points (corresponding to 0·5 sd), with a mean value of 260 points ⁽¹²⁾. With the same assumptions, we were able to detect a difference of 251 kJ (60 kcal) per d (corresponding to 0·5 sd) between groups in the present study.

Results

Study subject characteristics

At birth, 33 % of the infants were small for gestational age (birth weight < 10th percentile weight for gestational age), and the proportion of growth-restricted individuals increased to 58 % at discharge, on average 70 d after birth. Growth-restricted infants at discharge were characterised by a significantly higher proportion of small-for-gestational-age infants at birth (63 v. 11 %), more non-Caucasians (26 v. 11 %), shorter duration of respiratory support (11 v. 33 d) and higher gestational age at birth (29·6 v. 27·8 weeks), as compared with infants with adequate weight at discharge (Table 1). There was an indication of a shorter hospital stay among the growth-restricted compared with non-growth-restricted infants (66 v. 77 d; P = 0·06). There was no significant difference in birth weight or any maternal characteristics between growth-restricted infants and infants with adequate weight at discharge.

Table 1

Characteristics of mothers and infants

(Mean values and standard deviations)

SGA, small for gestational age.

* Length was measured in seventy-six infants at birth and in seventy-eight at discharge, due to different routines at the hospitals.

[dagger]

Fourteen infants in the growth-restricted group and eighteen infants with adequate growth were discharged before 37 weeks.

[double dagger]

Infants receiving recommended energy intake: >500 kJ/kg per d.

Diet

All but four infants in the growth-restricted group and all but one among those with adequate growth received parenteral nutrition. The volume of parenteral nutrition, however, was small (mean 9·45 ml/d) according to the routines at the departments, and the mean intake did not differ between groups. Full enteral feeding (defined as 150 ml/kg per d) was achieved after a median of 7 d. Two of the infants were treated for necrotising enterocolitis (both in the growth-restricted group). During the hospitalisation, 76 % of the infants received human milk from their own mother and 24 % from a combination of mother's and donor milk.

Energy and nutrient intake

Growth-restricted infants at discharge were characterised by significantly lower intakes of energy, protein and fat, and there was an indication of lower intakes of vitamin A, vitamin D and Ca as compared with infants with adequate weight for age at discharge. The overall energy intake did not differ between groups when expressed as kJ/kg per d (Table 1).

The growth-restricted infants had a lower energy intake during the study period compared with infants with adequate growth and there was a significant interaction between PCA and growth status at discharge (P_interaction < 0·001) (Fig. 1(a)). The energy intake per kg body weight was lowest in the first month of life, where only 16 % of the growth-restricted and 23 % of infants with adequate weight at discharge reached the recommended intake (500 kJ/kg per d). In the second period (29-33 weeks PCA), 48 % of the growth-restricted and 72 % of infants with adequate weight at discharge reached the recommended intake, and the difference between groups was significant ( P < 0·001). After 37 weeks, the energy intake per kg body weight decreased in both groups. A similar pattern was observed for protein intake (data not shown), as energy and protein were highly correlated in this group.

Fig. 1

(a) Intake of energy among growth-restricted infants at discharge (n 74; - - -) and infants with adequate weight at discharge (n 53; --). Values are means, with standard deviations represented by vertical bars. There was a significant interaction between post-conceptional age and growth status at discharge (P < 0·001). (b) Body weight among study infants (n 127; - - -) compared with the reference intra-uterine growth chart (--, mean; --, 10th percentile) for Norwegian infants⁽¹³⁾. For the study infants, values are means, with 95 % CI represented by vertical bars.

Growth-restricted boys had a slightly higher energy intake compared with the girls (757 v. 705 kJ/d), but there were no apparent sex differences in intake of energy and protein per kg body weight.

Growth

The weight gain compared with expected intra-uterine growth rate⁽¹³⁾ is shown in Fig. 1(b). Infants with adequate growth had higher growth rate compared with growth-restricted infants between 29 and 32 weeks of age (P < 0·001) (Table 1). The growth rate was lower than the estimated intra-uterine growth rate (15 g/kg per d) for both groups of infants in the beginning ( < 28 weeks PCA) and at the end (>37 weeks PCA) of the study period. The time period of the most pronounced growth restriction was different in infants with extremely low birth weight (ELBW; birth weight < 1000 g) as compared with infants with birth weight 1000-1500 g. ELBW infants had lower weight gain in the beginning of the study period ( < 28 weeks PCA: 8·6 g/kg per d) than later (after 28 weeks PCA: 17·6 g/kg per d; P < 0·001). Infants with birth weight 1000-1500 g had the lowest weight gain at the end of the study period (>37 weeks PCA: 8·9 g/kg per d, < 37 weeks PCA: 16·4 g/kg per d; P < 0·001). We did not find any sex difference in growth, neither for the total period nor for subperiods of hospitalisation in the study.

Association between nutrient intake and growth restriction at discharge

Association between nutrient intake, anthropometric factors and growth restriction at discharge was only examined in infants of adequate weight for age at birth (n 74). In the crude analyses, we found that weight ratio at birth (actual weight/50th percentile weight for gestational age at birth) and ethnicity were associated with growth restriction at discharge (Table 2). We did not observe any significant association between growth restriction and gestational age at birth, duration of respiratory support or sex. Mutual adjustment for all variables did not change these findings (Table 2).

Table 2

Associations between clinical variables, dietary intake and growth restriction (body weight <10th percentile) among infants with adequate weight for gestational age at birth (n 74)

(Odds ratios and 95 % confidence intervals)

* Growth restriction/adequate growth.

[dagger]

Adjusted for weight ratio at birth and ethnicity. Protein, fat and Ca are also energy adjusted by the residual method, and energy is included in the models for these variables.

We observed reduced odds of becoming growth restricted with increasing energy intake during the study period: crude OR = 0·28 for the second tertile and 0·11 for the upper tertile of the energy intake (P_trend = 0·001) (Table 2). The OR were only slightly changed after adjustment for birth weight ratio and ethnicity (Table 2). Additional adjustment for gestational age (weeks), respiratory support (d), length of hospitalisation (d) and sex did not change the results (data not shown).

There were significant associations between growth restriction and intake of protein, fat and Ca. However, after adjustment for energy intake, we did not find any protective effect of single nutrients (Table 2) although we noticed a positive trend for energy-adjusted fat intake ( P = 0·06).

Discussion

The present study shows that extra-uterine growth restriction is common in VLBW infants fed fortified human milk. Furthermore, we found an association between high energy intake and risk for growth restriction at discharge. The proportion of growth-restricted infants at discharge was 58 % in the present study, which is lower than the 89-97 % reported by others using formula ^(11,16,17). In the present study, human milk was used from the first day of life and throughout the whole observation period. This may provide several advantages such as better and faster tolerance for enteral feeding and fewer infections, contributing to improved growth ^(5,6). Moreover, the infants in the present study were born >5-10 years later than those reported in the previous studies and may thus have benefited from general improvements in medical care and treatment. Clark et al.⁽¹⁸⁾ reported a lower incidence of growth-restricted infants at discharge (28 %), but the mean birth weight of their infants was high compared with the infants in the present study (1·7 v. 1·1 kg). Different infant growth standards were used in these studies, which also must be taken into consideration. The Norwegian growth chart has slightly higher weights compared with the international growth chart⁽¹⁹⁾, but the difference is small. When calculations are done with Babson & Benda's growth chart, the proportion of growth-restricted infants at discharge was 55 % in the present study.

The major strength of the present study is the very detailed information on nutrient intake calculated on the basis of medical records. Moreover, the participants were consecutively included from four different neonatal units, which justifies the assumption that they are representative of the population of VLBW infants in Norway. An advantage with a weight- rather than length-based endpoint was that weight is more accurately measured than length, especially in very small infants. However, adequate weight for age is not necessarily equivalent to adequate growth. Increased weight gain may reflect increased adiposity rather than symmetric weight and length growth. Ideally, measurement of body composition should be included in these types of studies.

The currently recommended energy intake is 440-540 kJ/kg per d for growing preterm infants, and 500 kJ/kg per d is often used as a goal⁽¹⁰⁾. In the present study, the energy intake fell short of this, most markedly in the beginning and at the end of the study period. The low intake during the first weeks was expected, and in accordance with earlier reports^(20,21). The low energy intake during the end of the hospital stay was associated with low growth rate. This was somewhat surprising, and has to our knowledge not been described earlier. We speculate that this may be due to the high frequency of breast-feeding reported for the Norwegian population, and thereby cessation of the energy and protein fortification of the human milk. Especially the infants with few medical complications and higher gestational age were introduced to early breast-feeding and cessation of fortification at an early stage. Most of these infants also had a shorter hospital stay than infants with low gestational age and medical complications. This might be one reason why infants with higher gestational age and short hospital stay received lower energy supply and had a more pronounced decline in growth towards the end of the hospital stay. Infants with medical complications were on the contrary kept in hospital for a longer time period and thereby received parenteral nutrition and fortified human milk longer to cover their nutrient needs. It is not known if the positive effect of exclusive early breast-feeding outweighs the negative effect of growth failure at this age, as opposed to continuation of feeding with fortified human milk.

Postnatal growth failure is due to a complex interaction of genetic and environmental factors, including inadequate nutrition, morbidity affecting nutrient requirements and metabolism, endocrine abnormalities and treatments⁽²²⁾. After adjustment for possible confounders, only low energy intake, birth weight ratio and ethnicity were independently associated with growth restriction. Berry et al.⁽²³⁾ found that growth failure may be related to the use of dexamethasone and duration of respiratory support to ELBW infants, and that low energy intake was regarded as a consequence of the medical condition. Among infants with adequate weight at birth, we did not find any association between respiratory support, use of dexamethasone and growth failure.

We did not observe any significant association between growth restriction and intake of protein or Ca after adjusting for energy, probably because energy supply and nutrient supply were strongly correlated. We noticed a positive trend between growth restriction and fat intake (energy adjusted), but the OR were not significant.

Although the boys had a slightly higher energy intake compared with the girls in the small-for-gestational-age group, we were not able to detect any sex difference in energy and protein intake per kg body weight, or in growth. This may be due to low statistical power.

Growth restriction in VLBW infants may lead to altered brain function, promoting impaired long-term neurodevelopment and reduced intelligence quotient^(24,25). These observations are supported by several animal studies, for example, showing decreased hippocampal size in undernourished rat pups⁽²⁶⁾.

In humans it has been shown that catch-up growth is beneficial because it is associated with higher head circumference and higher intelligence quotient in adulthood⁽²⁷⁾. On the other hand, catch-up growth may also represent a risk factor for the development of CHD and the metabolic syndrome later in life. This is probably due to altered programming of endothelial function, as well as changes in the expression of important growth factor receptor binding ligands such as insulin and leptin ^(28-31). In preterm infants, the potential beneficial effect of catch-up growth on the central nervous system may outweigh the increased risk of cardiovascular heart disease, thus adequate growth should be prioritised⁽²⁹⁾. The optimal solution would be to characterise individual energy supply to ensure proper growth of the central nervous system without excessive accumulation of adipose tissue.

Conclusion

Extra-uterine growth restriction is common in VLBW infants fed fortified human milk. Recommended energy intakes for growing preterm infants were not met in the present study. We observed a significant positive association between energy intake and reduced risk of growth restriction at discharge. The present study shows that preterm infants have low weight gain in the beginning and at the end of the hospital stay. The smallest ELBW infants, who have high co-morbidity and require a long period on parenteral nutrition, have the lowest weight gain in the first month of life. The relatively large preterm infants, characterised by early full enteral feeding and initiation of breast-feeding without fortification, have the lowest weight gain in the last period before discharge. From the design of the present study, we cannot definitely conclude that the observed association between energy intake and growth restriction reflects a casual effect, and further studies are needed to examine this question. Further studies are also needed to evaluate the safety and efficacy of increased energy and nutrient intake to obtain adequate growth, with minimal adverse effects, in preterm infants.

Acknowledgements

C. H., C. A. D. and P. O. I. designed the study and were responsible for the data analyses and writing of the manuscript. C. H. was responsible for the data collection and wrote the first draft of the manuscript. A. C. W., A. R. and B. N. participated in the collection and analysis of data and contributed to the writing of the manuscript. M. B. V. was responsible for the statistical analyses and contributed to the writing of the manuscript.

We thank the medical and nursing staff at Akershus University Hospital, Buskerud Hospital, Rikshospitalet University Hospital and Vestfold Hospital for excellent collaboration.

Financial support for the present study was obtained from the Norwegian Foundation for Health and Rehabilitation, the Johan Throne Holst Foundation for Nutrition Research, Freia Medical Research Foundation, the Research Council of Norway and Thematic Program on Perinatal Nutrition, Faculty of Medicine, University of Oslo.

The funding does not pose any conflicts of interest to the study. 

References

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AuthorAffiliation

1 Department of Nutrition, Faculty of Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
2 Department of Pediatrics, Oslo University Hospital Rikshospitalet, Oslo, Norway
3 Department of Pediatrics, Akershus University Hospital and Akershus Faculty Division, Akershus, Norway
4 Biostatistics, Faculty of Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
5 Department of Haematology, Oslo University Hospital, Ullevaal, Oslo, Norway

Kehamilan ektopik atau juga dikenal sebagai kehamilan di luar kandungan merupakan suatu kondisi kehamilan dimana sel telur yang sudah dibuahi tidak mampu menempel atau melekat pada rahim ibu, namun melekat ada tempat yang lain atau berbeda yaitu di tempat yang dikenal dengan nama tuba falopi atau saluran telur, di leher rahim, dalam rongga perut atau di indung telur. Atau dengan kata lain, kehamilan ektopik meruapakan suatu kondisi dimana sel telur yang telah dibuahi mengalami implantasi pada tempat selain tempat seharunya, yaitu uterus. Jika sel telur yang telah dibuahi menempel pada saluran telur, hal ini akan menyebabkan bengkaknya atau pecahnya sel telur akibat pertumbuhan embrio.

Kehamilan ektopik menimpa sekitar 1% dari seluruh kehamilan dan hal ini merupakan suatu kondisi darurat dimana dibutuhkan pertolongan secepatnya. Karena jika dibiarkan kondisi ini sangat berbahaya dan mampu mengancam nyawa ibu, hal ini disebabkan oleh perdarahan dalam rongga abdomen, dan bukan terjadinya perdarahan keluar. Dalam kasus kehamilan ektopik, janin memiliki kemungkinan yang sangat kecul untuk dapat bertahan hidup. Namun di sejumlah kondisi kecil, contoh pada kehamilan abdominal, kehamilan dan janin bisa bertahan hingga masa persalinan dan jika persalinan dilakukan dengan cara caesar, maka ada harapan serta kemungkinan bayi untuk dapat bertahan hidup.

Penyebab Kehamilan Ektopik

Kehamilan ektopik biasanya disebabkan oleh berbagai hal, dan yang paling sering adalah disebabkan adanya infeksi pada saluran falopi (tuba falopi -  fallopian tube). Kehamilan ektopik besar kemungkinan terjadi pada kondisi:

• Ibu pernah mengalami kehamilan ektopik sebelumnya (terdapat riwayat kehamilan ektopik)
• Ibu pernah mengalami operasi pembedahan pada daerah sekitar tuba falopi
• Ibu pernah mengalami Diethylstiboestrol (DES) selama masa kehamilan
• Kondisi tuba fallopi yang mengalami kelainan kongenital
• Memiliki riwayat Penyakit Menular intimual (PMS) seperti gonorrhea, klamidia dan PID (pelvic inflamamtory disease)

Gejala Kehamilan Ektopik

Pada saat usia kehamilan mencapai usia 6-10 minggu, biasa ibu hamil yang mengalami kehamilan ektopik akan mengalami gejala:

• Ibu hamil mengalami rasa sakit pada daerah panggul salah satu sisinya dan biasanya terjadi dengan tiba-tiba
• Mengalami kondisi perdarahan alat kelamin di luar jadwal menstruasi atau menstruasi yang tidak biasa
• Mengalami rasa nyeri yang sangat pada daerah perut bagian bawah
• Ibu hamil mengalami pingsan

Gejala tahap lanjut pada kehamilan ektopik

• Rasa sakit perut yang muncul akan terjadi semakin sering
• Gejala lainnya adalah kulit ibu hamil terlihat lebih pucat
• Adanya tekanan darah rendah (hipotensi)
• Terjadinya denyut nadi yang meningkat

Diagnosa

Kehamilan ektopik biasanya sangat sulit di diagnosa oleh dokter, karena gejala dan tanda kehamilan ektopik juga biasanya terjadi pada kehamilan normal. Ada beberapa cara yang bisa dilakukan untuk mendeteksi terjadinya kehamilan ektopik, yaitu dengan cara:

• Menggunakan USG (ultrasonography). Melalui usg dokter dapat mendeteksi kehamilan ektopik karena tuba falopi terdetek mengalami kerusakan dan terjadinya perdarahan atau terdeteksi di luar uterus terdapat embrio
• Melalui pengukuran terhadap kadar HCG (human chrionic gonadotopin - hormon kehamilan). Ibu hamil yang mengalami ektopik biasanya kadar hcg nya tidak mengalami peningkatan
• Dilakukannya pembedahan dengan sayatan kecil di bagian bawah perut (laparoskopi)

Pengobatan

Dokter akan selalu membatalkan kondisi kehamilan ektopik dengan cara pemberian obat-obatan untuk menahan perkembangan embrio. Efek jangka panjang akan dapat terhindarkan jika, kehamilan ektopik dapat terdekteksi sejak dini. jika kehamilan ektopik telah terdektesi sejak dini, hal ini dapat ditangani dengan pemberian obat suntik agar dapat diserap oleh tubuh ibu hamil, hal ini dapat menyebabkan kondisi tuba falopi masih dalam keadaan utuh. Jika kondisi serius, seperti jika tuba falopi telah mengembang, maka dokter akan melakukan operasi.

Prognosa

Sekitar 12% wanita akan kembali mengalami kehamilan ektopik, ketika sebelumnya juga pernah mengalami ektopik. Wanita akan kembali menjadi subur kembali setalah mengalami kehamilan ektopik (60%), trauma berat setalah mengalami kehamilan ektopik dan akibatnya tidak ingin mengalami kehamilan kembali (30%) serta sekitar 10% wanita akan memiliki masalah kesuburan setelah mengalami kehamilan ektopik.

Dukungan positif suami, saudara, atau teman terdekat akan sangat diperlukan bagi wanita yang mengalami kehamilan ektopik. Hal ini diharapkan dapat mengurangi pengalaman traumatic dari kehamilan ektopik, sehingga recovery dan keinginan untuk hamil kembali bisa secapatnya pulih (tentunya melihat kondisi setelah mengalami kehamilan ektopik). Konsultasikan kondisi anda kepada dokter atau bidan jika anda ingin hamil kembali setelah mengalami kehamilan ektopik. Hal ini sangatlah penting untuk dilakukan, agar dokter atau bidan dapat memberikan langkah-langkah yang harus di tempuh untuk menghindari kembali terjadinya kehamilan ektopik. Dan jika, memutuskan untuk hamil kembali, maka pengawasan ketat terhadap kehamilan berikutnya sangat diperlukan, guna menjaga agar kehamilan tetap berlangsung dengan baik hingga masa persalinan nanti.

I love my mother,
because she gave me life.
I love her because she makes me food and she raises me.

You taught me to hold
Tears pouring rain
To always be patient in the trial
Prostration and kneeling on the Lord ...

You couplet formed by prayer
Take care of the crime
Sweep me away by the dust
That will make me fall ...

You are an inspiration in life
Leads to sweep the obstacles
With that build confidence
Patience and care to create ...

You are a hero throughout the ages
Sweat makes science
Crying makes light guide
Dusk making a new spirit ...

You set the clouds
Will not disappear by the moon
Your love is eternal
Until later I had a dream in a grave ...

Where you stand
Place last steps
Share Them all miss the place
And a place to complain ...

You (the mother) there is no indelible
By the swift exposure to sea
By the anger of the earth ground
My heart and will always be an integral ...