低體重嬰兒(SGA)的未來智商與認知功能表現

註. 低體重(SGA)嬰兒(Small for gestational age/IUGR)大約占所有新生兒的10-15%, 常有較高的週產期併發症與死亡率, 以及未來的各種慢性器官疾病, 並且也有較體重適重嬰兒為低的智商與認知能力表現.

嬰兒標準體重表 台灣錯用40年

轉載來源: 張翠芬／台北報導 中國時報2008.11.01

這是一篇多年以前發表的文章

註: 台灣的兒童健康手冊早已經改成使用WHO的生長標準, 

然而在門診時大部分家長(>70%以上)卻不知道, 

更令人傷心的是許多家長(>80%以上)並不知道如何判讀使用生長曲線

(因為沒有認真閱讀此一手冊), 甚至如何為自己寶寶做生長測量都不清楚.

    　國內目前使用的「嬰兒標準體重表」有誤！醫師指出，衛生署提供給母親的參考標準，根本是錯誤的，使大部分嬰兒吸收了過量的營養，不但容易變成小胖子，未來將增加糖尿病、心臟病罹患機率；世界衛生組織已經修正，國內卻未跟進。

    　中華民國新生兒醫學會理事、敏盛醫院副院長周怡宏醫師指出，世界衛生組織近幾年已經更新「嬰兒標準體重表」。因為過去四十年來，醫生提供給母親的標準，是建立在錯誤的研究數據上，當時研究人員用的是吃配方牛奶的嬰兒數據，而吃配方牛奶的嬰兒體重，通常比正常吃母乳的嬰兒重很多。

養出胖娃娃 易患糖尿病心臟病

    　周怡宏表示，根據英國兒童生長發育基金會提供的數據，英國母乳餵養嬰兒在一周歲時的平均體重是廿二磅，而完全吃配方牛奶長大的嬰兒在一周歲時的平均體重為廿三磅。根據英國政府的調查，英國百分之廿五的中學生都超重，這個數字是十年前的一倍。

    　按照過去的「嬰兒標準體重表」來檢查，一般吃母乳的嬰兒都會顯得瘦小，因此母親就會錯誤的為嬰兒增加不必要的營養。周怡宏指出，參與制訂世界衛生組織新標準的醫學專家都認為，舊的錯誤標準造成不正確的餵養方法，正是目前全世界都出現兒童過胖的根源之一。

數據來自吃配方奶嬰兒 易超重

    　周怡宏說，母乳餵養嬰兒長得慢，主要是嬰兒能夠主動調節身體所需的營養，睡眠方式也跟吃配方牛奶的嬰兒不同。吃配方牛奶的嬰兒大多吸收了過多的不必要營養，結果導致肥胖。

    　周怡宏表示，世界衛生組織已在二○○三年發布新的「嬰兒標準體重表」，這是根據全球六個國家八千個純母乳餵養的嬰兒完成統計，適合母乳餵養嬰兒的標準體重。

ＷＨＯ新標準 適合吃母乳嬰兒

    　根據新的標準，一歲大的女童體重九公斤，男童九．六公斤；五歲大的女生十八．二公斤，男生十八．三公斤。但國內目前的標準建議，一歲女童為九．五公斤，男童十公斤；五歲女生十八．五公斤，男生十九公斤，至少較新標準重○．五到一公斤，容易讓孩子「胖」在起跑點。

    　周怡宏表示，家長若發現自己的孩子體重較現行的標準稍低，毋需過度緊張，因為國內現在用的是舊標準，容易讓孩子過重。

 兒童依附關係的形成與類型及未來演變

Attachment and child development依附關係與孩子的發展

Last updated: 10 Aug 2021

轉載來源 NSPCC

https://learning.nspcc.org.uk/child-health-development/attachment-early-years

# What is attachment theory and why is it important?依附理論與重要性

Attachment is a clinical term used to describe "a lasting psychological connectedness between human beings” (Bowlby, 1997)¹.

In particular, attachment theory highlights the importance of a child’s emotional bond with their primary caregivers.

Disruption to or loss of this bond can affect a child emotionally and psychologically into adulthood, and have an impact on their future relationships.

Only specially trained and qualified professionals should assess a child’s attachment style. However, it’s important for all adults working with children to understand what attachment is and know how to help parents and carers become attuned to their child’s needs. You might do this by working with them directly, or by signposting families to other appropriate services. In the long term, this can help improve wellbeing and provide positive outcomes for both the child and their caregivers.

# Understanding attachment in the early years 依附在兒童早期的發展

Children can form attachments with more than one caregiver, but the bond with the people who have provided close care from early infancy is the most important and enduring (Bowlby, 1997)².

It’s important that parents and carers are attuned and responsive to their baby’s needs and are able to provide appropriate care. This includes recognising if their baby is hungry, feeling unwell or in need of closeness and affection (Howe, 2011)³.

Forming an attachment is something that develops over time for a child, but parents and carers can start to form an emotional bond with their child before they are born. Sometimes a parent or carer may have difficulty forming this bond, for example if they are experiencing mental health issues or don’t have an effective support network.

On this page, you’ll find information on:

·         why attachment is important

·         how children develop attachment

·         attachment issues, insecure and secure attachment and behaviours to look out for

·         how trauma can affect attachment

·         how you can support parents and carers to develop a bond with their child.

 Need specific information?

Our information specialists are here to help you find research, guidance and best practice.

# Stages of attachment

The first two years of a child’s life are the most critical for forming attachments (Prior and Glaser, 2006)⁴.

During this period, children develop an ‘internal working model’ that shapes the way they view relationships and operate socially. This can affect their sense of trust in others, self-worth and their confidence interacting with others (Bowlby, 1997)⁵.

 # When are attachments formed?依附怎麼形成的?

Attachments are formed in different ways during the phases of a child’s development.

Antenatal (before birth)

During the antenatal period, parents and carers can form a bond with their child. Any bonds formed before birth can have a positive impact on the relationship between babies and their caregivers once the child is born (Condon and Corkindale, 1997)⁶.

Birth until 6 weeks

This is sometimes referred to as the pre-attachment phase because the baby doesn’t appear to show an attachment to any specific caregiver. However, parents and carers who provide a nurturing environment and are responsive to their babies needs can lay the foundation for secure attachments to form (Bowlby, 1997)⁷.

6 weeks until 6-8 months

During this stage of their development, a baby might start to show a preference for their primary and secondary caregivers (often the mother and father).

6-8 months until 18 months-2 years

During this period a child begins to show a strong attachment to their primary caregivers. Babies start to develop separation anxiety during this phase and can become upset when their caregiver leaves, even for short periods (Bowlby, 1997)⁸.

18 months – 2 years onwards

At this point children are likely to become less dependent on their primary caregiver, particularly if they feel secure and confident the caregiver will return and be responsive in times of need (Bowlby, 1997)⁹.

 # Types of attachment依附的形式

A child’s need for attachment is part of the process of seeking safety and security from their caregiver. 

(1)   What does secure attachment look like?安全型依附

In secure caregiver-child relationships, the caregiver is usually sensitive and tuned in to the child’s needs. They are able to provide care that is predictably loving, responsive and consistent.

Young children who have formed a secure attachment to their caregiver may display the following patterns of behaviour during times of stress or exploration:

·         proximity maintenance – wanting to be near their primary caregiver

·         safe haven - returning to their primary caregiver for comfort and safety if they feel afraid or threatened

·         secure base – treating their primary caregiver as a base of security from which they can explore the surrounding environment. The child feels safe in the knowledge that they can return to their secure base when needed

·         separation distress - experiencing anxiety in the absence of their primary caregiver. They are upset when their caregiver leaves, but happy to see them and easily comforted when they return

(Ainsworth et al, 2015)¹⁰.

 Benefits of secure attachment

When caregivers react sensitively to ease their child’s distress and help them regulate their emotions, it has a positive impact on the child’s neurological, physiological and psychosocial development (Howe, 2011)¹¹.

Children with secure attachments are more likely to develop emotional intelligence, good social skills and robust mental health (Howe, 2011)¹².

 (2)   Effects of insecure attachment不安全型依附的結果

Not receiving comfort and security in the early years can have a negative effect on children’s neurological, psychological, emotional and physical development and functioning (Newman, 2015)¹³.

Babies and young children who have attachment issues may be more likely to develop behavioural problems such as attention deficit hyperactivity disorder (ADHD) or conduct disorder (Fearon et al, 2010)¹⁴.

Children who have attachment issues can have difficulty forming healthy relationships when they grow up. This may be because their experiences have taught them to believe that other people are unreliable or untrustworthy (Bowlby, 1997)¹⁵.

Adults with attachment issues are at a higher risk of entering into volatile relationships and having poor parenting skills, behavioural difficulties and mental health problems (Howe, 2011)¹⁶.

> Find out more about how trauma affects child brain development

 

Attachment issues

# Factors affecting attachment影響依附的重要因素

Some circumstances can make it more challenging for a child and their caregivers to form a pattern of secure attachment. These may include:

·         abuse, maltreatment and trauma experienced by the parent or child

·         parental mental health difficulties

·         parental substance misuse

·         the child having multiple care placements

·         parents being separated from their baby just after birth, for example if the baby is receiving neonatal care

·         stress such as having a low income, being a single parent, or being a young parent

·         bereavement or loss of another caregiver that a child had an attachment with

(Bowlby, 1989)¹⁷.

 # Signs that a child may have attachment issues依附問題的徵兆

Children’s behaviour can be influenced by a wide range of circumstances and emotions. Indicators that a baby or toddler might not have a secure attachment with their caregiver will emerge as a pattern of behaviour over time, particularly during moments of stress or exploration. This pattern might include:

·         being fearful or avoidant of a parent or carer

·         becoming extremely distressed when their carer leaves them, even for a short amount of time

·         rejecting their caregiver’s efforts to calm, soothe, and connect with them

·         not seeming to notice or care when their caregiver leaves the room or when they return

·         being passive or non-responsive to their carer

·         seeming to be depressed or angry

·         not being interested in playing with toys or exploring their environment

(Howe, 2011)¹⁸.

 

As children with attachment issues get older, these behaviour patterns might evolve. As well as being evident during times of stress, some behaviours may start to become obvious at other times. These may include the child:

·         finding it difficult to ask for help

·         struggling to form positive relationships with adults and peers

·         struggling to concentrate

·         struggling to calm themselves down

·         both demanding and rejecting attention or support at the same time

·         becoming quickly or disproportionately angry or upset, at times with no clear triggers

·         appearing withdrawn or disengaged from activities

·         daydreaming, being hyperactive or constantly fidgeting or moving

(Mentally Healthy Schools, 2020)¹⁹.

 

If you think a child may have attachment issues, you should refer them to a suitably trained health and social care professional for a full assessment. You should follow your organisation’s procedures to make a health and social care referral, or contact your local authority children’s social care services.

# Trauma and attachment創傷對依附的影響

The signs of attachment issues can be similar to indicators that a child is experiencing other challenges, such as:

·         mental health problems

·         additional needs

·         abuse and neglect.

This means it’s important to consider everything that’s going on in a child’s life and make sure they and their family are provided with appropriate support.

Think about all your previous experiences with the child and their caregivers, to help you build a clear picture of their relationships and rganizat any concerning patterns of rganiza.

The impact of trauma and attachment

Children who have experienced abuse, neglect and trauma might develop coping strategies that can make it more complicated to rganizat attachment issues.

For example, one sign of secure attachment is that children see their caregiver as a secure base to explore from. But children who have experienced neglect, for example, might display independent rganiza in order to protect themselves from the emotional pain of not having their needs met (Marvin et al, 2002)²⁰.

It is also possible for a child to develop an attachment to someone who is maltreating them (Blizard & Bluhm, 1994)²¹.

As well as affecting attachment, experiencing trauma can have an impact on a child’s brain development. Children might need extra support to help strengthen the architecture of their brain.

> Find out more about how trauma affects child brain development

What to do if you’re worried that a child is experiencing or at risk of abuse or neglect

If a child is in immediate danger, call the police on 999.

If you’re worried about a child but they are not in immediate danger, you should share your concerns.

·         Follow your rganization’s child protection procedures without delay. These should provide clear guidelines on the steps you need to take if a child discloses abuse. They will state who in your rganization has responsibility for safeguarding or child protection and who you should report your concerns to.

·         Contact your local child protection services. Their contact details can be found on the website for the local authority the child lives in.

·         Contact the police. They will assess the situation and take the appropriate action to protect the child.

·         Contact the NSPCC Helpline on 0808 800 5000 or by emailing help@nspcc.org.uk. Our trained professionals will talk through your concerns with you, give you expert advice and take action to protect the child as appropriate. This may include making a referral to the local authority.

Supporting children and families

Building positive relationships

It’s important for anyone who works with children and families to support parents and carers in building positive relationships with their child. Having positive interaction and play with caregivers can help a child’s brain to develop healthily.

> See our early years resources which you can share with parents and caregivers

Video feedback programmes can also be used by specially trained social care professionals to help caregivers improve their interactions with their child. This involves caregivers being filmed when they are interacting with their child and then watching the recording with a trained practitioner, who gives them feedback and helps them build on their strengths.

Support for parents and carers

If parents are struggling with their own issues, it may make it harder for them to bond with their child and provide consistant and responsive care. They may have:

·         experienced abuse of trauma themselves

·         drug and/or alcohol dependencies

·         mental health issues.

> Find out more about parental mental health

> Learn more about parental substance misuse

Services for children and families

The NSPCC has many services that children and families can be referred to, from supporting parents and carers in taking care of their children to preventing sexual abuse and overcoming abuse.

Our services might be suitable for children and families you are working with:

·         Pregnancy in Mind helps parents who are at risk of or experiencing mild to moderate anxiety and depression during pregnancy. The service helps build parents’ capacity to provide sensitive, responsive care to their babies and keep these skills developed postnatally and as their children develop

 

孩子老是把話當「耳邊風」，小心聽力出問題！

** 兒童聽力檢查應該從新生兒開始/入學前時期也十分重要

轉載來源: 學前雜誌9904 保健最前線

文/周怡宏醫師  周怡宏小兒科診所院長/中山醫院特約兒科醫師

 

三歲的小傑是家中的獨生子，媽媽常為了他「心不在焉」、「講什麼都當作耳邊風」的行為而感到苦惱。才剛上幼兒園一星期，老師從小傑的學習狀況以及與他人互動的種種反應，懷疑他可能有聽力問題，要媽媽趕緊帶小傑去作檢查。但是媽媽心裡想：小傑在新生兒時期聽力篩檢很正常，怎麼可能有聽力問題呢？

聽力對嬰幼兒發展為什麼這麼重要？

人的聽覺系統能將外界各種聲音傳達給大腦，把我們和外界的人、事和物聯繫起來。對0～6歲幼兒來說，聽覺不僅是他瞭解周遭世界重要的管道，此時期也是幼兒各項學習、發展的關鍵期，若聽覺受損，將大大影響幼兒的認知、語言的學習和抽象觀念的瞭解，人際關係及身心健康也可能受到嚴重影響。

6個月前是孩子聽力矯治的黃金期，效果最好。但國外聽力障礙的相關統計資料卻指出，若沒有給予早期聽力篩檢，聽障兒常在2～3歲時，甚至更晚，才被爸媽懷疑有問題，許多聽障兒也常被大人誤以為故意不聽話或者心不在焉，以致錯失早期診斷與治療的機會。

嬰幼兒聽力受損對生活的4大影響

1. 影響各項新事物的學習

  研究顯示，兒童說話的發音、言語的表達，以及將來的讀寫能力，對新知識的吸收能力和智力發展，都與聽覺的敏銳程度息息相關。有聽力問題的孩子，由於接收外界的聲音少了，常有語言遲緩、咬字不清、表達能力差和對音樂、節奏反應遲鈍的問題；又因為聽不清楚或聽不見大人的指導，對學習影響很大。

2. 無法避開生活中的危險或傷害
   孩子的人身安全也離不開敏銳的聽覺。日常生活中許多危險，都是經由聲音的警示來避免的，如汽車喇叭聲，失火警鈴或腳步聲等。聽障兒若聽不見警報或不能辨別聲音的來源，在有危險的時候就不能及時地做出反應，後果可能不堪設想。
3. 有礙人際關係的發展
   在這個以聲音為主要溝通媒介的世界，聽覺不佳的孩子常需要別人重複說明，才能明白說話內容，因此，在學校常被老師認為不專心、反應遲鈍、理解能力差，在社交場合難以跟上同學、親友的話題，在電話中交談也力不從心，常有被隔離感。此外，當孩子聽不清楚別人說話的內容時，很容易造成誤會而影響了人際關係。
   
   
4. 對心理健康有負面影響
   為了避免與人溝通時的尷尬，聽覺不佳的孩子即使聽不清楚也不願請人重複說明，因此，這些孩子常顯得精神不集中，因成績偏低而缺乏自信、覺得孤立無助，對人或對事有過分敏感、易怒等行為，嚴重者甚至會自暴自棄、性格顯得孤癖。

哪些孩子是聽障的高危險族群？

造成嬰幼兒聽力損傷的原因有先天性與後天性兩種，以下，將容易發生聽障的高危險因素整理出來，請爸媽特別留意。

先天性因素

以下這幾類狀況的嬰兒較易罹患先天聽障，應該優先接受聽力篩檢。

‧遺傳性：父母親雙方家族有聽障家族史。

‧先天感染：母親在懷孕期間（尤其前3個月）感染腮腺炎、麻疹及細菌性腦膜炎、感冒等病毒性疾病，容易造成嬰兒產生感音神經性聽障。

‧ 體重偏低：出生時體重低於１５００克的嬰兒。

‧  出生時有缺氧現象：因為缺氧需機械性輔助呼吸5天或以上的嬰兒。

‧  有黃疸病史：出生時罹患需要換血治療新生兒黃疸的嬰兒。

‧頭頸部畸形：出生時有小耳症、外耳狹窄及低髮線等狀況的嬰兒。

 後天性因素

爸媽要特別注意的是，許多研究已顯示，即使新生兒聽力篩檢正常，有很多聽障是後天性的，或者漸進性的，也會使原本正常的孩子產生聽障問題。

‧後天感染：接近70～90％的嬰幼兒都得過中耳炎。感冒常併發的中耳炎或得過細菌性腦膜炎的孩子，必須特別留意聽力問題。

‧藥物毒性：自行購買或者過量使用某些抗生素給幼兒服用，易造成耳毒性而影響聽力。

‧物理性外傷：摑耳光或顳骨骨折等這類外傷也容易導致幼兒聽力受損。

‧    長期噪音：環境中長期存在工廠噪音、飛機聲或玩具噪音等，也會影響聽力。

嬰幼兒聽力保健，爸媽的3個行動

行動1.主動要求為新生兒進行聽力篩檢

   先天性聽力障礙約佔全部先天性疾病的80%左右，平均每一千個新生兒中，約有三個患有聽力障礙，可說是新生兒最常見的先天性疾病，而嬰幼兒聽力篩檢，是早期發現聽力障礙的最佳方法。相對美國各州已立法，強制要求醫療院所進行全面性新生兒聽力篩檢，台灣新生兒聽力篩檢一直未受到重視，仍屬於自費檢查項目。據估計，目前大約有30～40%醫療院所提供新生兒聽篩；只有將近一半的新生兒接受聽力篩檢。(註. 台灣自101年3月起已經全面給予新生兒聽力篩檢補助)

雖然目前各縣市衛生局對於幼稚園兒童會施予聽力檢查，以偵測後天性聽障以及未被早期檢測出的先天聽障。但研究指出，先天性聽力障礙的孩子，若能早期發現並於6個月前介入聽能復健，語言發展才能達到接近正常聽力的孩子。因此，主動要求進行嬰幼兒聽力評估，以期及早配戴合適的助聽器，並加入早期療育課程，對於有聽力問題的嬰兒有關鍵性的影響。 

行動2.平時多注意觀察幼兒的聽覺反應

不同年齡的嬰幼兒，對於聲音以及語言的反應能力，會隨著年齡的增加而愈趨複雜，爸媽可透過以下的聽覺能力觀察簡表作自我檢查；當３歲以下的孩子未能符合同年齡孩子所具有的能力時，或者３歲以上的孩子在半數和以上的項目無法符合，就表示可能有輕度或以上的聽障，請爸媽儘快帶孩子就醫，做進一步聽力檢查，並找出聽障的原因及適當的補救方法。
 

嬰幼兒聽覺能力警示訊號觀察簡表

0-3歲 嬰幼兒	1～3個月：不會被突如其來的聲音所驚嚇 3～6個月：不會尋找或望向說話的人或發聲的物體 6～9個月： 不會望向說話中提及的對象 9～12個月：不會根據指示做簡單的動作，例如：過來 12～15個月：仍未能講第一個字，例如：爸、媽、車、鞋 15～18個月：不會回應你在鄰房的呼喚 18～24個月：仍未能講簡單短句，例如：媽媽水 24～30個月：能表達詞彙少於100個字 30～36個月：仍未能講有4至5個字的句子
4-12歲 兒童	l 對新事物的吸收能力比其他兒童慢 l 常常需要別人重複，才能或仍不能明白意思 l 聽別人講話時，呆望著講者卻不能理解內容 l 有時聽見別人講話，有時卻聽不見 l 常常聽不見別人在背後的呼喚 l 對聆聽長時間的口述或交談，容易感到疲倦 l 小組討論時，難以跟上別人所說的話

行動3.對孩子的聽力有任何疑慮，應及早檢查與治療

嬰兒在1歲以前能否清楚地聽見周圍的聲音，對日後的發展與學習有很大的影響。研究資料顯示，不論何種程度的聽障，若能得到早期診斷及適當的治療、復健，聽力康復的成功率就越大，學習語言、和別人溝通和互動的能力也會獲得改善，而入學後學習成效也會比較好。

因此，每位爸媽都要謹記，對孩子的細心觀察永遠是最重要的，即使嬰幼兒現階段的聽覺能力觀察沒有問題，也不能排除有觀察不出的輕微聽障，或在日後罹患逐漸形成的聽障。爸媽應隨時留意嬰幼兒的聽覺反應和語言發展，如有任何懷疑，應立即與聽力檢查醫療院所的專家們聯繫。才能避免聽力問題對嬰幼兒日後的溝通技巧、語言發展、行為及學習等，造成可能的長期性負面影響。

BOX新生兒聽力篩檢1-3-6原則 美國國家衛生院(NIH)已於1993年提出全面性新生兒聽力篩檢模式， 指出嬰幼兒聽力篩檢、診斷與治療的時機應愈早愈好。 l   每位健康新生兒都應在１個月大之前完成聽力篩檢的複檢工作。 l   聽力篩檢異常的嬰兒，應在３個月大前進行確認性檢查。 l   患有永久性聽障的嬰兒，應在６個月大前配戴助聽器，家長也需參加聽覺口語法訓練課程。