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Fruits and vegetables in general are highly beneficial in the treatment of heart disease medicine upset stomach purchase lithium us. Apples especially contain heart stimulating properties and the patients suffering from the weakness of heart should make liberal use of apples and apple jams medicine 369 discount lithium 300mg with visa. Fresh grapes medicine interactions buy discount lithium, pineapples symptoms 6 days post embryo transfer generic lithium 150 mg mastercard, oranges treatment toenail fungus buy discount lithium line, custard apples medications rheumatoid arthritis cheap 300 mg lithium, pomegranaes and coconut water also tone up the heart. Grapes are effective in heart pain and palpitation of the heart and the disease can be rapidly controlled if the patient adopts an exclusive grapes diet for few days. Grape juice, especially will be valuable when one is actually suffering from a heart attack. Indian gooseberry or amla is considered an effective home remedy for heart disease. It tones up the functions of all the organs of the body and builds up health by destroying the heterogeneous elements and renewing lost energy. They are useful in normalising the percentage of blood cholesterol by oxidising excess cholesterol. One teaspoon of raw onion juice first thing in the morning will be highly beneficial in such cases. One tablespoonful daily after food is sufficient to prevent all sorts of heart troubles. Patients with heart disease should increase their intake of foods rich in vitamin E, as this vitamin promotes the functioning of the heart by improving oxygeneration of the cells. Many whole meal products and green vegetables, particularly outer leaves of cabbage are good sources of vitamin E. Vitamin C is also essential as it protects against spontaneous breaches in capillary walls which can lead to heart attacks. The stress of anger, fear, disappointment and similar emotions can raise blood fat and cholesterol levels immediately but this reaction to stress can do little harm if the diet is adequate in vitamin C and pantothenic acid. The following is the suggested diet for persons suffering from hypertension or some disorder of the heart: On rising: Warm water with lemon juice and honey or fresh fruit juice of apple, grapes, orange, pineapple. Breakfast: Fresh fruit such as apples, grapes, pears, peaches, pineapple, orange, melons, one or two slices whole meal toast, yogurt, skimmed milk or soya milk. Lunch: Combination salad of vegetables such as lettuce, cabbage, endive, carrots, cucumber, beetroot, tomato, onion and garlic. One or two slices of whole meal bread or chappatis, curd, fresh grapes and other fruits in season. Dinner: Fresh fruit or vegetable juice or soup, two lightly cooked vegetables, one or two whole. The patient should also pay attention to other laws of nature for health building such as taking moderate exercise, getting proper rest and sleep, adopting the right mental attitude and getting fresh air and drinking pure water. Water Treatment the use of an ice bag on the spinal area between the second and tenth thoracic vertebrae for 30 minutes three times a week, a hot compress applied to the left side of the neck for 30 minutes every alternate day and massage of the abdomen and upper back muscles are water treatments which are beneficial in cases of heart disease. To this may be added hot packs on the chest over the heart for one minute and a cold pack applied alternately for five minutes. Asanas such as shavasana, vajrasana, and gomukhasna, yogic kriyas like jalneti and pranayamas such as shitali, sitkari and bhramari are also helpful in providing relief to heart patients. Although it is essential to life, it has a bad reputation, being a major villain in heart disease. Every person with a high blood cholesterol is regarded as a potential candidate for heart attack, a stroke or high blood pressure. It is the principal ingredient in the digestive juice bile, in the fatty sheaths that insulate nerves and in sex hormones, namely, estrogen and androgen. It performs several functions such as transportation of fat, providing defense mechanism, protecting red blood cells and muscular membrane of the body. Some cholesterol is also secreted into the intestinal tract in bile and becomes mixed with the dietary cholesterol. The percentage of ingested cholesterol absorbed seemed to average 40 to 50 percent of the intake. Persons with atherosclerosis have uniformly high blood cholesterol usually above 250 mg. In blood, cholesterol is bound to certain proteins lipoproteins which have an affinity for blood fats, known as lipids. The low density lipoprotein is the one which is considered harmful and is associated with cholesterol deposits in blood vessels. Cholesterol has been the subject of extensive study by researchers since 1769, when French chemist, Polutier de La Salle purified the soapylooking yellowish substance. The results of the most comprehensive research study, commissioned by the National Heart and Lung Institute of the U. The 10year study, considered most elaborate and most expensive research project in medical history, indicates that heart disease is directly linked to the level of cholesterol in the blood and that lowering cholesterol significantly reduces the incidence of heart attacks. It has been estimated that for every one per cent reduction in cholesterol, there is a decrease in the risk of heart attack by two per cent. Causes Hyperchjolsterolaemia or increase in cholestrol is mainly a digestive problem caused by rich foods such as fried foods, excessive consumption of milk and its products like ghee, butter and cream, white flour, sugar, cakes, pastries, biscuits, cheese, ice cream as well as nonvegetarian foods like meat, fish and eggs. Other causes of increase in cholesterol are irregularity in habits, smoking and drinking alcohol. Adrenal glands of executive type aggressive persons produce more adrenaline than the easy going men. Consequently they suffer six to eight times more heart attacks than the relaxed men. The American Heart Association recommends that men should restrict themselves to 300 mg. It also prescribes that fat should not make up more than 30 per cent of the diet and not more than one third of this should be saturated. The Association, however, urges a somewhat strict regimen for those who already have elevated levels of cholesterol. Lecithin, also a fatty food substance and the most abundant of the phospholipids, is highly beneficial in case of increase in cholesterol level. It has the ability to break up cholesterol into small particles which can be easily handled by the system. With sufficient intake of lecithin, cholesterol cannot build up against the walls of the arteries and veins. It also increases the production of bile acids made from cholesterol, thereby reducing its amount in the blood. Egg yolk, vegetable oils, whole grain cereals, soyabeans and unpasteurised milk are rich sources of lecithin. The cells of the body are also capable of synthesizing it as needed, if several of the B vitamins are present. Diets high in vitamin B6, cholin and inositol supplied by wheat germ, yeast, or B vitamins extracted from bran have been particularly effective in reducing blood cholesterol. Sometimes vitamin E elevates blood lecithin and reduces cholesterol presumably by preventing the essential fatty acids from being destroyed by oxygen. Persons with high blood cholesterol level should drink at least eight to 10 glasses of water every day as regular drinking of water stimulates the excretory activity of the skin and kidneys. Regularly drinking of coriander (dhania) water also helps lower blood cholesterol as it is a good diuretic and stimulates the kidneys. It is prepared by boiling dry seeds of coriander and straining the decoction after cooling. It also promotes circulation and helps maintain the blood flow to every part of the body. Jogging or brisk walking, swimming, bicycling and playing badminton are excellent forms of exercise. Yogasnas are highly beneficial as they help increase perspiratory activity and stimulate sebaceous glands to effectively secrete accumulated or excess cholesterol from the muscular tissue. Asanas like ardhamatsyaendrasana, shalabhasana, padmasanaand vajrasana are useful in lowering blood cholesterol by increasing systemic activity. Steam baths are also helpful except in patients suffering from hypertension and other circulatory disorders. They improve the functioning of the liver and other digestive organs and activate kidneys and the intestines to promote better excretion. The fast pace of life and the mental and physical pressures caused by the industrial and metropolitan environments give rise to psychological tensions. Worry and mental tension increases the adrenaline in the blood stream and this, in turn, causes the pressure of the blood to rise. The blood which circulates through the arteries within the body supplies every cell with nourishment and oxygen. The force exert by the heart as it pumps the blood into the large arteries creates a pressure within them and this is called blood pressure. A certain level of blood pressure is thus essential to keep the blood circulating in the body. But when the pressure becomes too high, it results in hypertension which is caused by spasm or narrowing of the small blood vessels, known as capillaries, throughout the body. This narrowing puts more stress on the heart to pump blood through the blood vessels. Hence, the pressure of the blood to get through rises in proportion to the pressure on the heart. The blood pressure is measured with the instrument called sphygmomanometer in millimeters of mercury. The highest pressure reached during each heart beat is called systolic pressure and the lowest between the two beats is known as diastolic pressure. The first gives the pressure of the contraction of the heart as it pushes the blood on its journey through the body and indicates the activity of the heart. The second represents the pressure present in the artery when the heart is relaxed and shows the condition of the blood vessels. The blood pressure level considered normal is 120/70, but may go up to 140 /90 and still be normal. From 160/96 to 180/114, it is classed as moderate hypertension, while 180/115 and upward is considered severe. A raised diastolic pressure is considered more serious than the raised systolic pressure as it has a serious longterm effect. The first symptoms may appear in the form of pain toward the back of the head and neck on waking in the morning, which soon disappears. Some of the other usual symptoms of hypertension are dizziness, aches and pains in the arms, shoulder region, leg, back, etc. A person suffering from high blood pressure cannot do any serious work, feels tired and out of sorts all the time. Hypertension, if not eliminated, may cause heart attacks or strokes or other disability conditions such as detachment of the terina. Causes the most important causes of hypertension are stress and a faulty style of living. People who are usually tense suffer from high blood pressure, especially when under stress. If the stress continues for a longperiod, the pressure may become permanently raised and may not become even after removal of the stress. An irregular life style, smoking and an excessive intake of intoxicants, tea, coffee, cola drinks, refined foods, destroy the natural pace of life. The expulsion of waste and poisonous matter from the body is prevented and the arteries and the veins become slack. Other causes of high blood pressure are excessive intake of pain killers, common table salt, food allergies and eating a high fat, low fibre diet, processed foods deficient in essential nutrients. If increased rennin is secreted by the kidneys, more salts are retained in the body, which leads to an increase in the volume of circulating blood and consequently to an increase in the blood pressure. Repeated infections and inflammation in the kidneys can also give rise to hypertension. The Cure the modern medical treatment of high blood pressure is highly unscientific as it brings down the pressure by drugs without making any effort to remove the underlying causes. Drugs may temporarily reduce blood pressure, but they do not cure the condition and are harmful in the ultimate analysis. All drugs against hypertension without exception, are toxic and have distressing side effects. The natural way of dealing with it is to eliminate the poisons from the system which cause it. Persons with high blood pressure should always follow a wellbalanced routine of proper diet, exercise and rest. The pressure is lowered and blood clotting diminished by partaking of a higher fruit content, lower protein and nonflesh diet. A natural diet consisting of fresh fruits and vegetables, instead of a traditional diet, is helpful in getting rid of the poisons from the body. A hypertension patient should start the process of healing by living on an exclusive fruitdiet for atleast a week, and take fruits at fivehourly intervals thrice in the day. Oranges, apples, pears, mangoes, guava, pineapples, raspberry, watermelon are the best diet in such cases. If they are cooked, it should be ensured that their natural juices are not burnt in the process of cooking. Vegetables like cucumber, carrot, tomatoes, onion, radish, cabbage and spinach are best taken in their raw form. They may be cut into small pieces and sprinkled with a little salt and the juice of a lemon added to them so as to make them more palatable.

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However treatment for sciatica buy lithium 150mg, practical anatomy treatment quadricep strain 300mg lithium fast delivery, such as it is medicine vials order cheapest lithium and lithium, is concerned with an exact knowledge of the relationship of organs as they stand in reference to each other medications requiring aims testing discount 150mg lithium visa, and to the whole design of which these organs are the integral parts medicine 6 times a day order cheap lithium line. The figure treatment jellyfish sting buy lithium 300mg amex, the capacity, and the contents of the thoracic and abdominal cavities, become a study of not more urgent concernment to the physician, than are the regions named cervical, axillary, inguinal, &c. He who would combine both modes of a relationary practice, such as that of medicine and surgery, should be well acquainted with the form and structures characteristic of all regions of the human body; and it may be doubted whether he who pursues either mode of practice, wholly exclusive of the other, can do so with honest purpose and large range of understanding, if he be not equally well acquainted with the subject matter of both. It is, in fact, more triflingly fashionable than soundly reasonable, to seek to define the line of demarcation between the special callings of medicine and surgery, for it will ever be as vain an endeavour to separate the one from the other without extinguishing the vitality of both, as it would be to sunder the trunk from the head, and give to each a separate living existence. The necessary division of labour is the only reason that can be advanced in excuse of specialisms; but it will be readily agreed to , that that practitioner who has first laid within himself the foundation of a general knowledge of matters relationary to his subject, will always be found to pursue the speciality according to the light of reason and science. Anatomythe the knowledge based on principleis the foundation of the curative art, cultivated as a science in all its branchings; and comparison is the nurse of reason, which we are fain to make our guide in bringing the practical to bear productively. The human body, in a state of health, is the standard whereunto we compare the same body in a state of disease. The knowledge of the latter can only exist by the knowledge of the former, and by the comparison of both. It is a potent instrumentthe only one, in the hands of the pathologist, as well as in those of the philosophic generalizer of anatomical facts, gathered through the extended survey of an animal kingdom. We best recognise the condition of a dislocated joint after we have become well acquainted with the contour of its normal state; all abnormal conditions are best understood by a knowledge of what we know to be normal character. Every anatomist is a comparer, in a greater or lesser degree; and he is the greatest anatomist who compares the most generally. Impressed with this belief, I have laid particular emphasis on imitating the character of the normal form of the human figure, taken as a whole; that of its several regions as parts of this whole, and that of the various organs (contained within those regions) as its integrals or elements. And in order to present this subject of relative anatomy in more vivid reality to the understanding of the student, I have chosen the medium of illustrating by figure rather than by that of written language, which latter, taken alone, is almost impotent in a study of this nature. It is wholly impossible for anyone to describe form in words without the aid of figures. Even the mathematical strength of Euclid would avail nothing, if shorn of his diagrams. Anatomy being a science existing by demonstration, (for as much as form in its actuality is the language of nature, ) must be discoursed of by the instrumentality of figure. An anatomical illustration enters the understanding straightforward in a direct passage, and is almost independent of the aid of written language. The best substitute for Nature herself, upon which to teach the knowledge of her, is an exact representation of her form. If there may be any novelty nowadays possible to be recognised upon the out trodden track of human relative anatomy, it can only be in truthful and wellplanned illustration. Under this view alone may the anatomist plead an excuse for reiterating a theme which the beautiful works of Cowper, Haller, Hunter, Scarpa, Soemmering, and others, have dealt out so respectably. Except the human anatomist turns now to what he terms the practical ends of his study, and marshals his little knowledge to bear upon those ends, one may proclaim anthropotomy to have worn itself out. And that which Cruveilhier has done for human anatomy, Muller has completed for the physiological interpretation of human anatomy; Burdach has philosophised, and Magendie has experimented to the full upon this theme, so far as it would permit. Are we to put off the day of attempting interpretation for three thousand years more, to allow the human physiologist time to slice the brain into more delicate atoms than he has done hitherto, in order to coin more names, and swell the dictionaryfi The work must now be retrospective, if we would render true knowledge progressive. It is not a list of new and disjointed facts that Science at present thirsts for; but she is impressed with the conviction that her wants can alone be supplied by the creation of a new and truthful theory, a generalization which the facts already known are sufficient to supply, if they were well ordered according to their natural relationship and mutual dependence. We must return by the same road on which we set out, and reexamine the things and phenomena which, as novices, we passed by too lightly. That which I have said and proved elsewhere in respect to the skeleton system may, with equal truth, be remarked of the nervous systemnamely, that the question is not in how far does the limit of diversity extend through the condition of an evidently common analogy, but by what rule or law the uniform ens is rendered the diverse entityfi The womb of anatomical science is pregnant of the true interpretation of the law of unity in variety; but the question is of longer duration than was the life of the progenitor. Hilaire and Leibnitz, and Gothe, have lived and spoken, yet the present state of knowledge proclaims the Newton of physiology to be as yet unborn. The iron scalpel has already made acquaintance with not only the greater parts, but even with the infinitesimals of the human body; and reason, confined to this narrow range of a subject, perceives herself to be imprisoned, and quenches her guiding light in despair. Originality has outlived itself; and discovery is a longforgotten enterprise, except as pursued in the microcosm on the field of the microscope, which, it must be confessed, has drawn forth demonstrations only commensurate in importance with the magnitude of the littleness there seen. The subject of our study, whichever it happen to be, may appear exhausted of all interest, and the promise of valuable novelty, owing to two reasons:It may be, like descriptive human anatomy, so cold, poor and sterile in its own nature, and so barren of product, that it will be impossible for even the genius of Promethean fire to warm it; or else, like existing physiology, the very point of view from which the mental eye surveys the theme, will blight the fair prospect of truth, distort induction, and clog up the paces of ratiocination. The physiologist of the present day is too little of a comparative anatomist, and far too closely enveloped in the absurd jargon of the anthropotomist, ever to hope to reveal any great truth for science, and dispel the mists which still hang over the phenomena of the nervous system. He is steeped too deeply in the base nomenclature of the antique school, and too indolent to question the import of Pons, Commissure, Island, Taenia, Nates, Testes, Cornu, Hippocamp, Thalamus, Vermes, Arbor Vitro, Respiratory Tract, Ganglia of Increase, and all such phrase of unmeaning sound, ever to be productive of lucid interpretation of the cerebrospinal ens. What custom wills; should custom always do it, the dust on antique time would lie unswept, And mountainous error be too highly heaped, For truth to overpeer. As far as the subject of relative anatomy could admit of novel treatment, rigidly confined to facts unalterable, I have endeavoured to give it. The unbroken surface of the human figure is as a map to the surgeon, explanatory of the anatomy arranged beneath; and I have therefore left appended to the dissected regions as much of the undissected as was necessary. My object was to indicate the interior through the superficies, and thereby illustrate the whole living body which concerns surgery, through its dissected dead counterfeit. We dissect the dead animal body in order to furnish the memory with as clear an account of the structure contained in its living representative, which we are not allowed to analyse, as if this latter were perfectly translucent, and directly demonstrative of its component parts. The cervical surgical triangles considered in reference to the position of the subclavian and carotid vessels, &c. The parts endangered in surgical operations on the parotid and submaxillary glands, &c. The course of the carotid and subclavian vessels in reference to each other, to the surface, and to their respective surgical triangles. Relative position of the vessels liable to change by the motions of the head and shoulder. The operations for tying the carotid or the subclavian at different situations in cases of aneurism, &c. The operations of tracheotomy and laryngotomy in the child and adult, the right and left brachiocephalic arteries and their varieties considered surgically. Remarks on fractures of the clavicle and dislocation of the humerus in reference to the axillary vessels. Fractures of the cranium, and the operation of trephining anatomically considered. Relative capacity of the thorax and abdomen as influenced by the motions of the diaphragm. Symmetrical arrangement of the vessels arising from the median thoracico abdominal aorta, &c. Chronic enlargements of the liver and spleen as affecting the relative position of other parts. The saphenous opening, spermatic cord, and femoral vessels in relation to femoral hernia. The conjoined tendon, internal inguinal ring, and cremaster muscle, considered in reference to the descent of the testicle and of the hernia. Investments and varieties of the external inguinal hernia, its relations to the epigastric artery, and its position in the canal. The oblique changing to the direct hernia as to position, but not in relation to the epigastric artery. The taxis performed in reference to the position of both as regards the canal and abdominal rings. Median and lateral important parts to be avoided in lithotomy, and the operation for fistula in ano. Distortion of the canal by the enlarged third lobeby the irregular enlargement of the three lobesby a nippleshaped excrescence at the vesical orifice. General remarks on the causes of the various deformities, and of the formation of stone. The sacculated bladder considered in reference to sounding, to catheterism, to puncturation, and to lithotomy. Remarks on popliteal aneurism, and the operation for tying the popliteal artery, in wounds of this vessel. Its division, by the median line, into two great lateral fieldsthose subdivided into two systems or provinces viz. Their stages of metamorphosis simulating the permanent conditions of the parts in lower animals. Anastomosing branches of the systemic aorta considered in reference to the operations of arresting by ligature the direct circulation through the arteries of the head, neck, upper limbs, pelvis, and lower limbs. Practical observations on the most eligible situations for tying each of the principal vessels, as determined by the greatest number of their anastomosing branches on either side of the ligature, and the largest amount of the collateral circulation that may be thereby carried on for the support of distal parts. In the human body there does not exist any such space as cavity, properly so called. The thoracic space is completely filled by its viscera, which, in mass, take a perfect cast or model of its interior. The thoracic viscera lie so closely to one another, that they respectively influence the form and dimensions of each other. The thoracic apparatus causes no vacuum by the acts of either contraction or dilatation. When any organ, by its process of growth, or by its own functional act, forces a space for itself, it immediately inhabits that space entirely at the expense of neighbouring organs. When the heart dilates, the pulmonary space contracts; and when the thoracic space increases, general space diminishes in the same ratio. The mechanism of the functions of respiration and circulation consists, during the life of the animal, in a constant oscillatory nisus to produce a vacuum which it never establishes. These vital forces of the respiratory and circulatory organs, so characteristic of the higher classes of animals, are opposed to the general forces of surrounding nature. The former vainly strive to make exception to the irrevocable law, that "nature abhors a vacuum. The being is functional by relationship; and just as a pendulum is functional, by reason of the counteraction of two opposing forces, viz. The inspiration of thoracic space is the expiration of general space, and reciprocally. The thoracic space is a symmetrical enclosure originally, which aftercoming necessities modify and distort in some degree. The spaces occupied by the opposite lungs in the adult body do not exactly correspond as to capacity, O O, Plate 1. Neither is the cardiac space, A E G D, Plate 1, which is traversed by the common median line, symmetrical. The asymmetry of the lungs is mainly owing to the form and position of the heart; for this organ inclines towards the left thoracic side. The left lung is less in capacity than the right, by so much space as the heart occupies in the left pulmonary side. The general form of the thorax is that of a cone, I I N N, Plate 1, bicleft through its perpendicular axis, H M. The line of bicleavage is exactly median, and passes through the centre of the sternum in front, and the centres of the dorsal vertebral behind. Between the dorsal vertebral and the sternum, the line of median cleavage is maintained and sketched out in membrane. This membranous middle is formed by the adjacent sides of the opposite pleural or enveloping bags in which the lungs are enclosed. The heart, A, Plate 1, is developed between these two pleural sacs, F F, and separates them from each other to a distance corresponding to its own size. The adjacent sides of the two pleural sacs are central to the thorax, and form that space which is called mediastinum; the heart is located in this mediastinum, U E, Plate 1. The extent of the thoracic region ranges perpendicularly from the root of the neck, Q, Plate 1, to the roof of the abdomenviz. All this space is pulmonary, except the cardiac or median space, which, in addition to the heart, A, Plate 1, and great bloodvessels, G C B, contains the oesophagus, bronchi, &c. The ribs are the true enclosures of thoracic space, and, generally, in mammalian forms, they fail or degenerate at that region of the trunk which is not pulmonary or respiratory. In human anatomy, a teleological reason is given for thisnamely, that of the ribs being mechanically subservient to the function of respiration alone. But the transcendental anatomists interpret this fact otherwise, and refer it to the operation of a higher law of formation. The capacity of the thorax is influenced by the capacity of the abdomen and its contents. In order to admit of full inspiration and pulmonary expansion, the abdominal viscera recede in the same ratio as the lungs dilate. The diaphragm, P P, Plate 1, or transverse musculomembranous partition which divides the pulmonary and alimentary cavities, is, by virtue of its situation, as mechanically subservient to the abdomen as to the thorax. And under general notice, it will appear that even the abdominal muscles are as directly related to the respiratory act as those of the thorax. The connexion between functions is as intimate and indissoluble as the connexion between organs in the same body. There can be no more striking proof of the divinity of design than by such revelations as anatomical science everywhere manifests in facts such as thisviz. The apex of the lung projects into the root of the neck, even to a higher level, Q, Plate 1, than that occupied by the sternal end of the clavicle, K. If the point of a sword were pushed through the neck above the clavicle, at K, Plate 1, it would penetrate the apex of the right lung, where the subclavian artery, Q, Plate 1, arches over it.

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During the fetal period medications for adhd purchase 300mg lithium with mastercard, environmental exposure to agents such as cytomegalovirus treatment anal fissure order lithium line, Toxoplasma gondii medications on nclex rn buy lithium 150 mg low cost, herpes simplex virus symptoms kidney buy lithium from india, and highlevel radiation is known to induce microencephaly and microcephaly medications that cause dry mouth order 150 mg lithium with mastercard. Severe mental retardation may occur as a result of exposure of the embryo/fetus to high levels of radiation during the 8 to 16week period of development medications to treat bipolar order genuine lithium. Agenesis of the corpus callosum, partial or complete, is frequently associated with low intelligence in 70% of cases and seizures in 50% of patients. As in the present case, a large third ventricle may be associated with agenesis of the corpus callosum. The large ventricle exists because it is able to rise superior to the roofs of the lateral ventricles when the corpus callosum is absent. The mother had certainly contracted rubella or German measles during early pregnancy because her infant had the characteristic triad of anomalies resulting from infection of an embryo by the rubella virus. Cataract is common when severe infections occur during the first 6 weeks of pregnancy because the lens vesicle is forming. Congenital cataract is believed to result from invasion of the developing lens by the rubella virus. The most common cardiovascular lesion in infants whose mothers had rubella early in pregnancy is patent ductus arteriosus. Although a history of a rash during the first trimester of pregnancy is helpful for diagnosing the congenital rubella syndrome, embryopathy (embryonic disease) can occur after a subclinical maternal rubella infection. Congenital ptosis (drooping of superior [upper] eyelid) is usually caused by abnormal development or failure of development of the levator palpebrae superioris muscle. The congenital anomalies result from invasion of the fetal bloodstream and developing organs by Toxoplasma parasites. These parasites disrupt development of the central nervous system, including the eyes, which develop from outgrowths of the brain (optic vesicles). The physician would certainly tell the woman about Toxoplasma cysts in meat and advise the woman to cook her meat well, especially if she decided to have more children. He or she would tell the woman that Toxoplasma oocysts are often found in cat feces and that it is important to wash her hands carefully after handling a cat or its litter box. The infant had trisomy 18 because the characteristic phenotype of this type of trisomy is present. Lowset, malformed ears associated with severe mental deficiency, prominent occiput, congenital heart defect, and failure to thrive are all suggestive of the trisomy 18 syndrome. This numerical chromosomal abnormality results from nondisjunction of the number 18 chromosome pair during gametogenesis. Postnatal survival of these infants is poor, with 30% dying within a month of birth; the mean survival time is only 2 months. Detachment of the retina is a separation of the two embryonic retinal layers: the neural pigment epithelium derived from the outer layer of the optic cup and the neural retina derived from the inner layer of the cup. The intraretinal space, representing the cavity of the optic vesicle, normally disappears as the retina forms. The proximal part of the hyaloid artery normally persists as the central artery of the retina; however, the distal part of this vessel normally degenerates. Natal teeth may be supernumerary ones; however, they are often prematurely erupted primary teeth. If it is established radiographically that they are supernumerary teeth, they would probably be removed so that they would not interfere with the subsequent eruption of the normal primary teeth. Natal teeth may cause maternal discomfort resulting from abrasion or biting of the nipple during nursing. Tetracyclines become incorporated into the developing enamel and dentine of the teeth and cause discoloration. Dysfunction of ameloblasts resulting from tetracycline therapy causes hypoplasia of the enamel. Most likely the secondary dentition would also be affected because enamel formation begins in the permanent teeth before birth (approximately 20 weeks in the incisors). It is formed by an overgrowth of small blood vessels consisting mostly of capillaries; however, there are also some arterioles and venules in it. This type of angioma is quite common, and the mother should be assured that this anomaly is of no significance and requires no treatment. Formerly this type of angioma was called a nevus flammeus (flamelike birthmark); however, these names are sometimes applied to other types of angiomas. Nevus is not a good term because it is derived from a Latin word meaning a mole or birthmark, which may or may not be an angioma. A tuft of hair in the median plane of the back in the lumbosacral region usually indicates the presence of spina bifida occulta. This is the most common developmental anomaly of the vertebrae and is present in L5 and/or L1 in approximately 10% of otherwise normal people. Spina bifida occulta is usually of no clinical significance; however, some infants with this vertebral anomaly may also have a developmental defect of the underlying spinal cord and nerve roots. The superficial layers of the epidermis of infants with lamellar ichthyosis, resulting from excessive keratinization, consist of fishlike, grayishbrown scales that are adherent in the center and raised at the edges. Seven percent to 10% of congenital anomalies are caused by environmental factors such as drugs and chemicals. It is difficult for clinicians to assign specific defects to specific drugs for the following reasons: a fi the drug may be administered as therapy for an illness that itself may cause the anomaly. Women should know that several drugs, for example, cocaine, cause severe anomalies if taken during pregnancy and that these drugs should be avoided. Women older than the age of 35 years are more likely to have a child with Down syndrome or some other chromosomal disorder than are younger women (2530 years). The physician caring for a pregnant 40yearold woman would certainly recommend chorionic villi sampling and/or amniocentesis to determine whether the infant had a chromosomal disorder such as trisomy 21 or trisomy 13. A 44yearold woman can have a normal baby; however, the chances of having a child with Down syndrome are 1 in 25. Penicillin has been widely used during pregnancy for more than 30 years without any suggestion of teratogenicity. Small doses of aspirin and other salicylates are ingested by most pregnant women, and when they are consumed as directed by a physician, the teratogenic risk is very low. Chronic consumption of large doses of aspirin during early pregnancy may be harmful. The physician would certainly tell the mother that there was no danger that her child would develop cataracts and cardiac defects because she has German measles. He or she would undoubtedly explain that cataracts often develop in embryos whose mothers contract the disease early in pregnancy. They occur because of the damaging effect the rubella virus has on the developing lens. The physician might say that it is not necessarily bad for a girl to contract German measles before her childbearing years because this attack would probably confer permanent immunity to rubella. Therefore, it is prudent to avoid contact with the cats and their litter during her pregnancy. If the woman is pregnant, the parasite can cause severe fetal anomalies of the central nervous system such as mental retardation and blindness. This means the software is try before you buy software, the trial version includes some limitation, if you would like to use it in full version, you have to register your copy. Note: For more information about upgrading to take full advantage of all the features describe, please visit No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without prior written permission from the publisher. Suggested Citation: American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for our children: National health and safety performance standards; Guidelines for early care and education programs. Risley 2 3 4 5 6 7 8 9 10 Caring for Our Children: National Health and Safety Performance Standards Table of Contents Acknowledgements***. Table of Contents vi Caring for Our Children: National Health and Safety Performance Standards 9. We are pleased to build upon their foundational work in this Third Edition with new science and research. The National Resource Center for Health and Safety in Child Care would like to acknowledge the outstanding Technical Panel Chairs and Members contributions of all persons and organizations involved in the revision of Caring for Our Children: National Health and Child Abuse Safety Performance Standards: Guidelines for OutofHome Anne B. The third edition Every day millions of children attend early care and educa benefted from the contribution of eightysix technical ex tion programs. It is critical that they have the opportunity to perts in the feld of health and safety in early care and edu grow and learn in healthy and safe environments with caring cation. Reviews and recommendations were received from and professional caregivers/teachers. Following health and 184 stakeholder individuals those representing consumers safety best practices is an important way to provide quality of the information and organizations representing major early care and education for young children. The publication was the product of a outofdate, identifed those that were still applicable (in fve year national project funded by the U. Department of their original or in a revised form), and formulated many new Health and Human Services, Health Resources and Services standards that were deemed appropriate and necessary. This comprehensive set of health and safety standards was 2) Telephone conference calls were convened among a response to many years of effort by advocates for quality technical panel chairs to bring consensus on standards that child care. In the years that followed, experts repeatedly 4) this feedback was subsequently reviewed and consid reaffrmed the need for these standards. For example, while ered by the technical panels and a decision was made to the work to prepare Caring for Our Children was underway, further revise or not to revise a standard. Child Care Policy for the 1990s, called points of view and new information for additional discussion for uniform national child care standards (3). It Children has been a yardstick for measuring what has been is hard to enumerate in this introduction the countless hours done and what still needs to be done, as well as a technical of dedication and effort from contributors and reviewers. We have made the following signifcant content and format changes in the third edition: xvii Introduction Caring for Our Children: National Health and Safety Performance Standards Total of fftyeight new standards and ffteen new related to child health; the U. National health and safety Added related standards at the bottom of each performance standards: Guidelines for outofhome child care standard for easy referral. Policy issues in day care: Summaries of 21 We recognize that many organizations have requirements papers, 10915. Children with special health care needs encompass those who have or are at increased risk for a chronic physical, the following are the guiding principles used in writing these developmental, behavioral, or emotional condition and who standards: also require health and related services of a type or amount 1. The health and safety of all children in early care and beyond that generally required by children. The child care setting offers children who have intermittent and continuous needs in all many opportunities for incorporating health and safety aspects of health. No child with special health care needs education and life skills into everyday activities. Health should be denied access to child care because of his/her education for children is an investment in a lifetime of good disability(ies), unless one of the four reasons for denying health practices and contributes to a healthier childhood care exists: level of care required; physical limitations of the and adult life. Modeling of good health habits, such as site; limited resources in the community, or unavailability of healthy eating and physical activity, by all staff in indoor and specialized, trained staff. Whenever possible, children with outdoor learning/play environments, is the most effective special health care needs should be cared for and provided method of health education for young children. Child care for infants, young children, and schoolage children is anchored in a respect for the developmental 7. Children with and the importance of early brain development in young special needs should have a comprehensive interdisciplinary children and in particular children birth to three years of age. Written policies and procedures should identify facility activities should be geared to the needs of all children. The relationship between parent/guardian/family and child as to when the policy does or does not apply. Whenever possible, written information about facility Those who care for children on a daily basis have abundant, policies and procedures should be provided in the native rich observational information to share, as well as offer in language of parents/guardians, in a form appropriate for struction and best practices to parents/guardians. Parents/ parents/guardians who are visually impaired, and also in an guardians should share with caregivers/teachers the unique appropriate literacy/readability level for parents/guardians behavioral, medical and developmental aspects of their who may have diffculty with reading. Daily communication, combined tion must be maintained to protect the child, family, and with at least yearly conferences between families and the staff. The information obtained at early care and education principal caregiver/teacher, should occur. Parents/guardians must be assured and ensure all families, regardless of language, literacy level, of the vigilance of the staff in protecting such information. This portant to document key communication (verbal and written) nurturing enhances the enjoyment of both child and parent/ between staff and parents/guardians.

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Infants who are healthy and stable should remain with their mother during this period medicine quinidine order lithium american express. The infant should be kept warm and assessed by a detailed clinical examination that includes intra uterine growth status medicine tablets 300 mg lithium fast delivery, evaluation for gestational age symptoms 10 weeks pregnant buy lithium canada, and a comprehensive risk assessment for neonatal conditions that require additional monitoring or inter vention medicine you cannot take with grapefruit purchase generic lithium online. Shortly after birth medicine look up drugs lithium 300 mg, all infants are weighed; receive eye prophylaxis medications in canada buy discount lithium 300 mg line, parenteral vitamin K, skin care, and umbilical cord care; and are bathed and clothed. Initiation of breastfeeding should take place soon after birth, with continued monitoring of the breastfed newborn until discharge and then after by the newborn care provider. In the event breastfeeding is disrupted, breast milk may be collected and stored or pasteur ized banked donor milk may serve as an alternative. Preventive newborn care includes attention to hygiene and asepsis; hepatitis immunization; and screening for genetic and metabolic conditions, hearing impairment, critical congenital heart disease, risk of hyperbilirubinemia, and developmental hip dysplasia. Targeted assessment of temperature stability, 265 266 Guidelines for Perinatal Care glucose homeostasis, and possible sepsis are implemented on a discretionary basis, depending on individualized risk. Delivery Room Care Approximately 10% of newborns require some assistance to begin breathing that includes stimulation at birth, and less than 1% will need extensive resus citative measures. Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births, a sizable number will require some degree of resuscitation. Recognition and immediate resuscitation of a distressed neonate requires an organized plan of action that includes the imme diate availability of proper equipment and onsite qualified personnel. Although the guidelines for neonatal resuscitation focus on delivery room resuscitation, most of the principles are applicable throughout the neonatal period and early infancy. Each hospital should have policies and procedures addressing the care and resuscitation of the newborn, including the qualifica tions of physicians and staff who provide this care. A program should be in place that ensures the competency of these individuals as well as their peri odic credentialing. At every delivery, there should be at least one individual whose primary responsibility is the newborn and who is capable of initiating resuscitation, including positive pressure ventilation and chest compressions. Either this individual or someone else who is immediately available should have the skills required to perform a complete resuscitation, including endotracheal intubation, establishment of vascular access, and the use of medications. The provision of services and equipment for resuscitation should be planned jointly by the medical and nursing directors of the departments involved in resuscitation of the newborn, usually the departments of obstet rics, pediatrics, and anesthesia. A physician, usually a pediatrician, should be Care of the Newborn 267 designated to assume primary responsibility for initiating, supervising, and reviewing the plan for management of newborns requiring resuscitation in the delivery room. The following issues should be considered in this plan: A prioritized list should be developed of known or anticipated maternal and fetal complications that would require a routine, urgent, and an emergency delivery room presence of an individual(s) qualified in all aspects of newborn resuscitation. This is especially important because most resuscitation medications should be given by this route. Steps in Delivery Room Management At birth, the neonatal care team implements a sequence of steps to quickly assess and stabilize the infant in order to institute the appropriate intensity of newborn care. With careful consideration of risk factors, most newborns who will need resuscitation can be identified before birth. If the possible need for resuscitation is anticipated, additional skilled personnel should be recruited and the necessary equipment prepared. Assessment Newborns who do not require resuscitation should be identified by rapid assess ment of three characteristics: 1. The baby should be dried, placed skin toskin with the mother, and covered with dry linen to maintain temperature. The decision to progress beyond the initial steps is determined by simultane ous assessment of two vital characteristics: 1) respirations (apnea, gasping, or Care of the Newborn 269 Yes, stay Routine care Birth Term gestationfi Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Palpation of the pulse at the base of the umbilical cord is the easiest and quickest method to determine the heart rate. If a pulse is not palpable, assessment of heart rate should be done by auscultating the precordial heart tones. Once positive pressure ventilation with or without supplemental oxygen administration is begun, assessment should consist of simultaneous evaluation of three vital characteristics: 1) heart rate, 2) respira tions, and 3) the state of oxygenation (the latter optimally determined by a pulse oximeter). Infants who require stabilization or resuscitation should be placed under a preheated radiant warmer. The radiant warmer will reduce heat loss and allow easy access to the newborn during resuscitation procedures. An infant older than 28 weeks of gestation who requires resuscitation should be dried completely with prewarmed towels and placed under a preheated radiant warmer. Very low birth weight (less than 1, 500 g) preterm babies are likely to become hypothermic despite the use of traditional techniques for decreasing heat loss. Because infants younger than 28 weeks of gestation may become hypothermic while being dried, they should be immediately covered up to their necks in polyethylene wrap or a foodgrade plastic bag and placed under a radiant warmer. When the newborn is vigorous (defined as having strong respiratory efforts, good muscle tone, and a heart rate greater than 100 beats per minute), there is no evidence that nasopharyngeal suctioning is neces sary. It is recommended that suctioning of the airway immediately after birth (including suctioning with a bulb syringe) should be reserved for babies who Care of the Newborn 271 have obvious airway obstruction that interferes with spontaneous breathing or who require positive pressure ventilation. The mouth should be suctioned before the nose so there is nothing to aspirate if the neonate gasps when the nose is suctioned. Vigorous suctioning of the posterior pharynx should be avoided because this may produce significant reflex bradycardia and may dam age the oral mucosa, leading to interference with suckling because of pain. When using suction from the wall or a pump, the suction pressure should be set so that negative pressure reads approximately 100 mm Hg when the suction tubing is blocked. The newborn can be positioned on either the back or the side, with the neck slightly extended. This position (known as the sniffing position) readily aligns the posterior pharynx, larynx, and trachea for optimal air entry, for both spontaneous breaths and bag and mask ventilation. However, if the infant does not have adequate respirations, some additional tactile stimulation may be needed. If the baby does not respond to one or two slaps, flicks to the feet, or rubbing of the back, positive pressure ventilation should be initiated. Published data indicate that positive pressure ventilation should be initiated with air in the term infant; however, the data regarding the preterm infant are less clear. The goal of resuscitation is to achieve an oxygen saturation value in the interquartile range of preductal saturations for each minute after birth measured in healthy term babies after vaginal birth at sea level (see table in. In the term infant, these targets can, in most instances, be achieved by initiating resuscitation with air. The oxygen concentration may be titrated, if needed, to achieve an Spo2 in the 272 Guidelines for Perinatal Care target range. It is recommended that oximetry be used when resuscitation can be anticipated, supplemental oxygen is administered, positive pressure is administered for more than a few breaths, or when cyanosis appears to persist. Because many babies born at less than 32 weeks of gestation will not reach target saturations when resuscitated with air, blended oxygen and air may be given judiciously and pulse oximetry should ideally be used to guide adjust ments to the amount of oxygen given. The normal newborn breathes within seconds of delivery and usually has established regular respirations within 1 minute after delivery. A newborn who is apneic or is gasping or whose heart rate is less than 100 beats per minute requires positive pressure ventilation. For most newborns, bag and mask ventilation is effective, can serve to stimulate the initiation of spontane ous respirations, and is the only resuscitation maneuver required to establish regular respirations. If the heart rate does not increase with ventilation, poor ventilation due to failure to establish functional residual capacity should be suspected. In this case, corrective steps, such as opening the mouth, suctioning the orophar ynx, and increasing the pressure used to deliver breaths should be considered. If resuscitation was initiated with air or blended oxygen and air, and there is no improvement in heart rate after 90 seconds of effective ventilation, the oxygen concentration should be increased to 100%. Endotracheal intubation may be performed at various points during resus citation, depending on the clinical circumstances. Indications for intubation include the following: the presence of meconium in a depressed infant Poor response to ventilation with mask and bag or Tpiece resuscitator To enhance coordination of ventilation and chest compressions when chest compressions are necessary Other possible indications for intubation include need for surfactant adminis tration, and suspected or known congenital diaphragmatic hernia. Individuals not adept at intubation should obtain assistance and focus on providing effective positive pressure ventilation with a mask rather than using valuable time attempting to intubate. Care of the Newborn 273 Exhaled carbon dioxide detection is the recommended method to confirm endotracheal tube placement; however, critically ill infants with poor cardiac output and poor or absent pulmonary blood flow may not exhale sufficient carbon dioxide to be detected reliably and thus may give falsenegative test results. As with bag and mask ventilation, effective assisted ventilation with an endotracheal tube should result in an increased heart rate. If the heart rate does not increase promptly above 60 beats per minute after at least 30 seconds of effective ventilation with oxygen, chest compressions should be instituted while ventilation is continued. There should be a 3:1 ratio of compressions to ventilations with approximately 90 compressions and 30 ventilations per minute. The use of medications for resuscitation of the newborn rarely is necessary in the delivery room and should be considered only after effective ven tilation and chest compressions have been established and the heart rate remains low. A list of drugs and volume expanders for resuscitation, with appropriate dosages, should be readily available, preferably in a prominent place in the resus citation area. The efficacy of endotracheal epinephrine is unproven, and use of this route results in lower and unpredictable blood levels that may not be effective. Physicians may choose to give an endotracheal tube dose while the umbilical venous catheter is being placed. It should be given by the most accessible route, which in the delivery room is usually the umbilical vein. It may be advisable to give the infusion more slowly in preterm infants because rapid infusion of large volumes may increase the risk of intraventricular hemorrhage. Adequate support of ventilation should be sufficient to restore normal heart rate and oxygenation. Apgar Score the Apgar score is useful for describing the status of the newborn at birth and his or her subsequent adaptation to the extrauterine environment. It should not be used to determine the need for resuscitation or the steps to be taken. If resus citation is indicated, it is initiated before the 1minute Apgar score is obtained. Apgar scores should be assigned at 1 minute and 5 minutes after birth, and if the 5minute Apgar score is less than 7, additional scores should be assigned every 5 minutes for up to 20 minutes until the Apgar score is greater than 7. Assessment of the Newborn in the Delivery Room After delivery, the newborn must be assessed for individual needs to determine the best location for care. If the mother has chosen to breastfeed, the newborn should be placed at the breast in the delivery room within the first hour after birth. Initial skintoskin contact has been associated with a longer duration of breastfeeding and improved temperature stability. The nursing staff in the labor, delivery, recovery, and postpartum areas should be trained in assessing and recognizing problems in the newborn. Newborns with depressed breathing, depressed activity, or persistent cyano sis at birth who require intervention in the delivery room but respond promptly, or those with continuing symptoms, including mild respiratory distress, are at risk of developing problems and should be evaluated frequently during the immediate neonatal period. If the vital signs stabilize and the infant has no other risk factors, the newborn can then roomin with the mother. Infants who require more extensive resuscitation are at risk of developing subsequent complications and may require ongoing support. These infants should be managed in an area where ongoing evaluation and monitoring are available. This may take place in the birth hospital, if it is an appropriate facil ity, or may require transport to another hospital for a higher level of care. Immediate plans for the newborn should be discussed with the parents or other support person(s), preferably before leaving the delivery room. Whenever possible, the parents should have the opportunity to see, touch, and hold the newborn before transfer to a nursery or before transfer to another facility.

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Other a) State agencies with regulatory responsibility or an states have some symptoms narcolepsy generic lithium 300 mg line, but not all treatment 5th toe fracture discount lithium 150 mg on line, of these advisory bodies; interest in child care (human services medicine to stop runny nose buy lithium on line amex, public health medicine in motion buy discount lithium 300 mg, each of which has some relevance to child care medicine 906 generic lithium 300mg visa, but often fre marshal medicine woman dr quinn order genuine lithium on line, emergency medical services, education, with a different focus. Man and referral, early childhood education, and early dating the council by law will reduce the likelihood that the childhood professional development; council will be rendered ineffective by changes in political e) Parents/guardians who refect the diversity of the leadership or dissolved when its recommendations are not families that are consumers of licensed child care in agreement with a current administration. Participation of parent/guardian representatives in planning State and regional agencies should collaborate with employ and implementing early childhood initiatives at the state ers to facilitate arrangements for the care of children who and local levels promotes effective partnerships between are ill in the following settings: parents/guardians and caregivers/teachers (1). American participating small family child care homes, where Academy of Pediatrics. Local and state health departments, child care licensing Businesses should be encouraged to allow the use of paid agencies, education and health professionals, attorneys, sick leave for this purpose. However, when parent care puts caregivers/teachers, parents/guardians, and representatives the family income or parent employment at risk, the child of the business community, including employers, should should receive care that is appropriate for the child. Often, work together to develop child care licensing requirements when faced with the pressures of the workplace, parents/ and guidelines for children who are ill. To meet this responsibility, health depart ness, children need familiar caregivers/teachers and familiar ments generally have the expertise to provide leadership places where their illnesses and their emotional needs can and technical assistance to licensing authorities, caregivers/ be managed competently. The heavy reliance on the expertise of local and state health departments in the 10. In addition, the business commu ognized by the state child care regulatory agency should nity has a vested interest in assuring that parents/guardians credential or license all persons who provide child care or have facilities that provide quality care for children who are who may be responsible for children or who may be alone ill so parents/guardians can be productive in the workplace. The credential should be granted this vested interest is likely to produce meaningful contribu to individuals who meet age, education, and experience tions from the business community to creative solutions and qualifcations, whose health status facilitates providing safe innovative ideas about how to approach the regulation of and nurturing care, and who have no record of conviction facilities for children who are ill. All stakeholders in the care for criminal offenses against persons, especially children, of children who are ill should be involved for the solutions or confrmed act of child abuse. The state should establish that are developed in regulations to be most successful. The current system, in which the details background checks of a prospective employee and without of staff qualifcations and ongoing training are checked as having to hire before background checks have been com part of facility inspection, is cumbersome for child care ad pleted. By this means, children are not exposed to health ministrators and licensing inspectors alike. If staff qualifca and safety risks from understaffng, or to care by unquali tions were established as part of a separate, more central fed or even dangerous individuals employed provisionally process, the licensing agency staff could check center because the results of a check are not yet available to the records of character references and whether staff members director. Nursery crimes: over quality, encourage a career ladder with increasing qual Sexual abuse in day care. Such Every state should have a statute which mandates the a process is analogous to that provided for other education licensing agency or other authority to obtain a background professionals (teachers), and even those service providers screening that includes a criminal records check, a sex with less potential for harm than is involved in caring for offender registry check, and a child abuse registry check children (such as beauticians, barbers, taxi drivers). The expense of background screenings should be administrators, licensors, and child care personnel, who do a public responsibility. Public and private policymakers should use fnancial care providers who care for just a few children. Caregivers/ and other incentives to help caregivers/teachers meet cre teachers who care for more children are required to comply dentialing requirements. In nearly all States, colleges to offer courses appropriate for provider training regulations require background screenings for all child at times convenient for child care workers to attend and for care center staff. This screening requirement may protect other agencies to offer online courses available to providers children from abuse and reduce liability risks (1). The requirement for renewable certifcation they have been implemented, has become an additional is likely to deter people from applying for work in child care fnancial burden on programs, which are forced to pass as a way of gaining access to children for sexual purposes on the expense to parents/guardians or staff. Placing the since the process would include a background screening burden on potential new staff, volunteers, and substitute that includes a check of the sex offender registry and child caregivers/teachers themselves proves to be another disin abuse registry (1). In many cases juvenile records are sealed and verifcation offce where this transcript should be continually cannot be used for the purposes of background screen updated. Most state by state licensing agency staff for evidence of behavior that regulations are not clear on whether sex offender registries would disqualify an individual for work in specifed child are to be checked (2). Evidence of a recent health examination indicat Some states have established defnitions for regular vol ing ability to care for children can be submitted at the same unteers (for whom criminal record and child abuse registry time. The center director then knows whether job applicants checks should be required) and for shortterm visitors, such who have been working in the feld previously are qualifed as entertainers and others, who will not be unsupervised at the time they apply for the job, without lengthy waiting for with the children. Informa ical and emotional abuse may or may not be the purview of tion on how to call and how to report should be posted in the licensing agency. This responsibility may fall to another licensed facilities so it is readily available to parents/guard agency to which the licensing agency refers child abuse ians and staff. This responsibility may fall to another agency to Public authorities (such as licensing agencies) and private which the licensing agency refers child abuse allegations. Regulations should be available to parents/guardians and State agencies should encourage the arrangement and interested citizens upon request and should be translated if coordination of and the fscal support for consultants from needed. Licensing inspectors throughout the state should the local community to provide technical assistance for pro be required to offer assistance and consultation as a regular gram development and maintenance. Consultants should part of their duties and to coordinate consultation with other have training and experience in early childhood education, technical assistance providers as this is an integral part of early childhood growth and development, issues of health the licensing process. Child care staff is rarely trained health range for other public agencies, private organizations or professionals. Since staff and time are often limited, caregiv technical assistance agencies (such as a resource and refer ers/teachers should have access to consultation on avail ral agency) to make the following consultants available to able resources in a variety of felds (such as physical and the community of child care providers of all types: mental health care; nutrition; safety, including fre safety; a) Program consultant, to provide technical assistance oral health care; developmental disabilities; and cultural for program development and maintenance and sensitivity) (1, 2). Consultants should be chosen the public agencies can facilitate access to children and on the basis of training and experience in early their families by providing useful materials to child care childhood education and ability to help establish links providers. Child c) Nutritionist/registered dietitian, who also has the care health consultation improves health and safety policies and knowledge of infant and child development, food practices. The written agreement of small family child care homes in partnering with should be available at the time of an inspection visit. Early Childhood Education Consultants locating the appropriate materials and tools. There state mental health agency should promote funding are different models of mental health consultation. Some through community mental health agencies and child models are programmatic and only include the staff, others guidance clinics for these services. At the least, such work with individual children with behavioral and emotional consultants should be available when caregivers/ problems and the third model integrates both approaches. Develop child care homes in meeting the oral health needs of mental and behavioral pediatricians, child and adolescent children. The dental health consultant should have psychiatrists, and child psychologists are resources for the knowledge of pediatric oral health and be able to help behavioral and mental health needs of young children (1). To fnd such specialists, contact the manipulative skills, sensoryperceptual development, Department of Pediatrics at academic centers or the State social, psychosocial, and cultural constraints in motor Department of Mental Health. The faculty at such centers development, and development of cardiorespiratory can usually refer child care facilities to individuals with the endurance, strength and fexibility, and body necessary skills in their area. Minimum qualifcations required improvement issues); of consultants may be specifed in state regulations. There f) Local university kinesiology departments (on early are resources for training consultants. Providers, not the regulatory agency, role in promoting health and safety in child care. Chapter 10: Licensing/Community 404 Caring for Our Children: National Health and Safety Performance Standards 2. Impact of training on child care about assessment of specialized health care to the parents/ health consultant knowledge and practice. Outcomes of child care health consultation services for child care In addition, the regulatory agency should refer parents/ providers in New Jersey: A pilot study. Child medical home for assistance in development and formula care health consultation improves health and safety policies and tion of a written care plan to be used within a child care practices. A number of communi involved with the family may do this on behalf of the family, ties have Family Resource Centers, which are central points the parents/guardians should have every opportunity to play for information. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health community service agencies are beginning to recognize Bureau. Quality of care and use of the medical home in a the agency (or a council of such agencies) within the state statefunded capitated primary care plan for lowincome children. Opportunities for health promotion education in the hours of time spent by members of the multidisciplinary child care. Traditionally, these funds have they should receive no less than forty clock hours of orienta paid for individual therapists only, and not for others who tion training upon employment (1). This tradition of receive no less than twentyfour clock hours of continu restrained spending inhibits effective service delivery for ing education each year (1), covering the following topics children and families (1). Contact information for each state can be found at: regulations; perfdata. Department of Health and Human Services, Health e) Child development, early childhood education Resources and Services Administration, Maternal and Child Health principles, child care programming, scheduling, and Bureau. This this attitude results in improved selfesteem and mental is particularly true for areas not usually within the network health in children from all backgrounds. Facilities may be of early childhood professionals, such as health and safety able to attract participants from different income and cul expertise. Unless the licensing inspector is competent and tural groups by paying attention to the location of the facility able to recognize areas where facilities need to improve and available subsidies for low income families. Diversity in and monitor child care facilities, it is critical that licensing in programming: Family day care quality assurance Factsheet #4. In addition, be initially and periodically assessed by simultaneous, Chapter 10: Licensing/Community 406 Caring for Our Children: National Health and Safety Performance Standards independent monitoring by a skilled licensing inspector as caregivers/teachers. States should establish procedures until the trainee attains the necessary skills. Consistency in to ensure compliance of the training requirement by agency interpretation of licensing rules is essential for effective and personnel. Achieving consistency across inspectors throughout the state is diffcult to achieve and maintain. Every state should have tection of children, licensing inspectors should undergo individual standards that are applied to the following types periodic retraining and reevaluation to assess their ability to of facilities: recognize sound and unsound practices. States are beginning to put c) Dropin facility: A child care program where children interpretive guidelines on their Websites for ready use by are cared for over short periods of time on a one providers. Licensing staff must be trained on the interpretive time, intermittent, unscheduled and/or occasional guidelines and treat it as a living document which is fre basis. Dropin care is often operated in connection quently reviewed and revised as interpretation is refned. Docu e) Facility for children who are mildly ill: A facility ments used by the agency for achieving consistency should providing care of one or more children who are mildly be conveniently accessible to caregivers/teachers (1). Achieving the vision: A workbook for human f) Integrated or small group care for children who are care regulatory agencies. For example, child care for should be at least as well informed about child abuse issues seven to twelve children in the residence of the caregiver/ teacher may be referred to as family day care, a group day 407 Chapter 10: Licensing/Community Caring for Our Children: National Health and Safety Performance Standards care home, or a minicenter in different states. While it is not all persons over ten years of age who live in a small or large essential that each state use the same terms and some vari family child care home where child care is provided. Licensing and public regulation of early childhood programs: A position statement. An past fve years, the other state(s) where the individual epidemiologic profle of children with special health care needs. It is important to recognize and cannot be used for the purposes of background the relevance of health and safety in the quality criteria (1, 2). Department of Health and Human Services, Administration for Children and Families, National Child Care Information and Compliance Technical Assistance Center. Stair steps to quality: A guide for states and ment is being met by equivalent means and does not com communities developing quality rating systems for early care and promise the health, safety or protection of children (1). When unannounced time visiting and inspecting facilities to insure compliance inspections are used, they should be conducted at any hour with regulations the facility is in operation, i. Unannounced Complaints should be investigated promptly, based on inspections have been shown to be especially effective severity of the complaint. States are encouraged to post the when targeted to providers with a history of low compliance (1). Guides for day care facilities to achieve and maintain full compliance with licens licensing. Technical assistance and consultation provided the licensing agency should adopt monitoring strategies by licensing inspectors on an ongoing basis are essential that ensure compliance with licensing requirements. These to help programs achieve compliance with the rules and strategies should include the provision of technical as go beyond the basic level of quality.

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