B. Robert Meyer, MD
- Department of Medicine
- Weill Cornell Medical College
- New York Presbyterian Hospital
- New York, NY
Bleach baths can be a good treatment for children who do not have broken skin or eczema symptoms questions buy arava paypal. Bright Futures: Guidelines for Health Supervision of Infants symptoms 5-6 weeks pregnant proven 20 mg arava, Children symptoms 10 days before period buy arava with a visa, and Adolescents treatment pneumonia 20 mg arava sale, Third Edition medications like abilify discount arava 20mg overnight delivery. No part of this publication may be reproduced medicine plies buy discount arava online, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photo copying, recording, or otherwise, without prior written permission from the publisher. The Bright Futures initiative was launched in 1990 Goals of Bright Futures under the leadership of the Federal Maternal and Child! Increase family knowledge, skills, and participation in Futures Guidelines as a uniform set of recommendations health-promoting and prevention activities. Address the needs of children and youth with special Guidelines are the cornerstone of the Bright Futures initia health care needs through enhanced identification and tive and the foundation for the development of all Bright services. For more information about Bright Futures and available materials and resources, visit v brightfutures. Developmental Observation: Includes observation of How to Use this Guide parent-child interaction, developmental surveillance, and he Pocket Guide is based on Bright Futures: school performance questions. Guidelines for Health Supervision of Infants, T Children, and Adolescents, Third Edition. Presenting Physical Exam: Recommends a complete physical exam, key information from the Guidelines, the Pocket Guide including specific issues for each visit. Sections of the Pocket Guide Immunizations: Provides Centers for Disease Control Themes: Highlights 10 cross-cutting child health topics and Prevention/National Immunization Program and that are discussed in depth in the Guidelines. These American Academy of Pediatrics Red Book Web sites for themes are important to families and health care profes current schedules. The Pocket Guide lists these themes; families, organized by the 5 priorities of each visit. The Health Visit: Focuses on specific age-appropriate Guidance and questions in black type are intended for health and developmental issues. In addi tion, they have developed 5 priority health supervision topics for each visit. Help to start a conversation this unique curriculum, developed by a health promo-! Advocacy A summary of each of these core concepts is present Techniques ed on the following pages to help all professionals, both! Wait at least 3 seconds to allow the family to respond promotion curriculum, visit Promote view of health supervision as partnership join together to ensure health care delivery in a way that between child, family, health care professional, and recognizes the critical roles and contributions of each part community. Provide links between stated goals, health issues, and are 6 steps for building effective health partnerships: available resources in community. Approach child within context of family and information and identify appropriate guidance. Listen for verbal, and observe nonverbal, cues to consultant or local recreation centers. Introduce new information and reinforce healthy through with what we discussed today Health supervision visits present Four characteristics of the teachable moment opportunities for the health care professional to teach the child and family. Review the data and resources to be sure they support with the media, community groups, or legislators). Recognize that health care professionals and families can learn from one another about effective advocacy. Families demonstrate a ences in development, physical health, and mental health wide range of beliefs and priorities in how they structure for all children. This edition of the Bright Cultural Competence Futures Guidelines places special emphasis on 3 areas of Cultures form around language, gender, disability, sexual vital importance to caring for children and families. Even peo ple who have been fully acculturated within mainstream Children and Youth With Special Health Care Needs society can maintain values, traditions, communication As of 2000, more than 9 million children in the United patterns, and child-rearing practices of their original cul States have special health care needs. Immigrant families, in particular, face many cultural of every 5 households includes a child with a develop stressors. Family-centered care that promotes strong children and families from backgrounds other than their partnerships and honest communication is especially im own to listen and observe carefully, learn from the family, portant when caring for children and youth with special and work to build trust and respect. At the same time, the impact of specialness or exten sive health care needs should not overshadow the child. Their unique ability to choose what is best for their children must be recognized. The use of complementary and alternative care is par ticularly common when a child has a chronic illness or condition. Parents are often reluctant to tell their health care professional about such treatments, fearing disap proval. Health care professionals should ask parents directly, in a nonjudgmental manner, about the use of complementary and alternative care. Consultation with colleagues who are knowledgeable about complementary and alternative care might be nec essary. Discussion with a complementary and alternative care therapist also may be useful. Promoting Community Relationships and Resources the Bright Futures Guidelines provide an in-depth, state-of-the-art discussion of these themes, with evidence regarding effectiveness of health promotion interventions at specific developmental stages from birth to early adult hood. Health care professionals can use these compre hensive discussions to help families understand the xix Bright Futures Health Supervision Visits his section presents all the Bright Futures Visits from the Prenatal Visit to the 21 Year Visit. Discuss the purpose and importance of the newborn (Observe parent with partner, other children, other family screening tests (metabolic, hearing) that will be done in members. How are your resources for How do you, your family, the father feel about your pregnancy Would you be interested in resources that would help you afford to care for you and your baby Are they tags; nasal patency, septal deviation; cleft lip or palate, comfortable when feeding, holding, or caring for the natal teeth, frenulum; heart rate/rhythm/sounds, heart baby Note back/spine/foot deformi Surveillance of Development: Has periods of wakeful ties. Detect ness, is responsive to parental voice and touch, is able to primitive reflexes. Complete, including: Measure and Universal: Metabolic and Hemoglobinopathy; Hearing plot length, weight, head circumference; plot weight-for Selective: Blood Pressure; Vision length. What do you do when Infant capabilities, parent-child relationship, sleep (location, you get upset Are you concerned about having enough money to buy food for bad smell, redness, fluid from the area. What suggestions have you heard about things you can do to keep your baby healthy Assess/Observe posture, neurologic tone, activity level, symmetry of movement, state regulation. Surveillance of Development: Is able to sustain peri ods of wakefulness for feeding, will gradually become Screening (See p 58. Are there times Anticipatory Guidance when you feel sad, hopeless, or overwhelmed Observation of Parent-Child Interaction: Do reflexes, eye color/intensity/clarity, opacities, clouding of parents appear content, depressed, angry, fatigued, cornea. Has your partner or ex ideal; iron-fortified formula is recommended substitute; partner ever hit you Are you scared that you or other caretakers recognize signs of hunger, fullness; develop feeding may hurt the baby Plot weight-for parents appear content, depressed, angry, fatigued, over length. Are parents comfortable and confident with eyes/eyelids, ocular mobility, pupil opacification, red the infant Perform around feeding/eating, comforting, and responding to in Ortolani/Barlow maneuvers. Assess/Observe rashes, bruising; positional skull parents and infant demonstrate reciprocal engagement deformities; ocular mobility for lateral gaze, pupil opacifi around feeding/eating Assess/Observe developmental hip dyspla sia; neurologic tone, strength, and movement symmetry. Surveillance of Development: Smiles spontaneously, elicits social interactions, shows solidified self-consolation Screening (See p 58. Assess/Observe rashes, bruising; ocular mobility, parents and infant responsive to one another Who are calming/putting self to sleep, crib safety) you able to go to when you need help with your family Fluoride, oral hygiene/soft toothbrush, avoidance of bottle in How does your baby communicate or tell you what he wants and bed needs Can infant move away from parent to mobility, eye alignment, pupil opacification, red reflexes. Has your partner or ex Discipline (parenting expectations, consistency, behavior partner ever hit you Are you scared that you or other caretakers management), cultural beliefs about child-rearing, family may hurt the baby How does parent react to praise from health care profes Observe for stranger avoidance. Does parent ask child many questions or give marks, bruising; caries, plaque, demineralization, staining, many directions Complete, including: Measure and plot recumbent length, weight, head circumference. Surveillance of Development: Imitates adults, plays Assess language acquisition/clarity. How child communicates, expectations for language What do you think your child understands Does the child use plot standing height (preferred) or recumbent length, questions and phrases at appropriate age level
Cornea is approximately 80% of its adult size in treatment 2 buy 20 mg arava with amex, being fully grown at the age of 3 years symptoms e coli buy arava online pills. It is possible to see with only one eye treatment in spanish buy 10 mg arava overnight delivery, but three-dimensional vision is impaired when only one eye is used specially in relation to the judgement of distance medications similar to adderall quality 20 mg arava. It maintains the shape of the eye and gives attachment to the extraocular muscles medicine dictionary prescription drugs buy arava online. The sclera becomes thin (seive-like membrane) at the site where the optic nerve pierces it medicinenetcom medications buy discount arava 20 mg online. It divides the anterior segment of the eye into anterior and posterior chambers which contain aqueous humour secreted by the ciliary body. It consists of endothelium, stroma, pigment cells and two groups of plain muscle fibres, one circular (sphincter pupillae) and the other radiating (dilator pupillae). It consists of non-striated muscle fibres (ciliary muscles), stroma and secretory epithelial cells. It extends from the ora serrata up to the aperture of the optic nerve in the sclera. Macula lutea is a yellow area of the retina situated in posterior part with a central depression called fovea centralis. Embryology and Anatomy 5 the sclera, ciliary body and iris the lens and suspensory ligament (Cornea has been removed) (Iris has been removed) 2. Aqueous Humour Both anterior and posterior chambers contain a clear aqueous humour fluid secreted into the posterior chamber by the ciliary epithelium. It passes in front of the lens, through the pupil into the anterior chamber and returns to the venous circulation through the canal of Schlemm situated in the angle of anterior chamber. Lens Lens is a transparent, circular, biconvex structure lying immediately behind the pupil. It is suspended from the ciliary body by the suspensory ligament or zonule of Zinn. Vitreous Vitreous is a transparent, colourless, inert gel which fills the posterior 4/5 of the eyeball. Eyebrows Eyebrows are two arched ridges of the supraorbital margins of the frontal bone. Eyelids and Eyelashes the eyelids are two movable folds of tissue situated above and below the front of each eye. The tears then pass into the lacrimal sac (via the two canaliculi), nasolacrimal duct and finally into the nasal cavity (inferior meatus). Extraocular Muscles of the Eye the eyeballs are moved by six extrinsic muscles, attached at one end to the eyeball and at the other to the walls of the orbital cavity. Movement of the eyes to look in a particular direction is under voluntary control but co-ordination of movement needed for convergence and accommodation to near or distant vision, is under autonomic control. The superior oblique rotates the eyeball so that the cornea turns in a downward and outward directions. The inferior oblique rotates the eyeball so that the cornea turns upwards and outwards. These are branches of the ophthalmic artery, which is one of the branch of the internal carotid artery. Venous Drainage Venous drainage is done by the short ciliary veins, anterior ciliary veins, 4 vortex veins and the central retinal vein. This can be demonstrated by passing white light through a glass prism which refracts or bends the rays of the different colours to a greater or lesser extent, depending on their wavelengths. In a rainbow, white light from the sun is broken up by raindrops which act as prisms and reflectors. White light broken into the colours of the visible spectrum when passed through a prism the Spectrum of Light the spectrum of light is broad but only a small part is visible to the human eye. The visible spectrum extends from 723 nm at the red end to 397 nm at the violet end or roughly 700 to 400 nm. A specific colour is perceived when only one wavelength is reflected by the object and all the others are absorbed. Objects appear white when all wavelengths are reflected, and black when they are all absorbed. Although these may be considered as separate processes, effective vision is dependent upon their coordination. Before reaching the retina light rays pass successively through the conjunctiva, cornea, aqueous fluid, lens and vitreous. They are all more dense than air and with the exception of the lens, they have a constant refractory power similar to that of water. Lens the lens is a biconvex elastic transparent structure suspended behind the iris from the ciliary body by the suspensory ligament. All light rays entering the eye need to be bent (refracted) to focus them on the retina. Light from distant objects needs least refraction and as the object comes closer, the amount needed is increased. To increase the refractive power the ciliary muscle contracts, releasing its pull on the suspensory ligament and the anterior surface of the lens bulges forward, increasing its convexity. When the ciliary muscle relaxes it slips backwards, increasing its pull on the suspensory ligament, making the lens thinner. Size of the Pupil Pupil size influences accommodation by controlling the amount of light entering the eye. If the pupils were dilated in a bright light, too much light would enter the eye and damage the retina. In a dim light, if the pupils were constricted, insufficient light would enter the eye to activate the photosensitive pigments in the rods and cones which stimulate the nerve endings in the retina. The iris consists of one layer of circular and one of radiating smooth muscle fibres. Contraction of the circular fibres constricts the pupil, and contraction of the radiating fibres dilates it. The size of the pupil is controlled by the nerves of the autonomic nervous system. Sympathetic stimulation dilates the pupil and parasympathetic stimulation causes contraction of the pupil. Movements of the Eyeballs-convergence Light rays from objects enter the two eyes at different angles and for clear vision they must stimulate corresponding areas of the two retinae. Extraocular muscles move the eyes and to obtain a clear image they rotate the eyes so that they converge on the object viewed. When there is voluntary movement of the eyes both eyes move and convergence is maintained. The nearer an object is to the eyes the greater the eye rotation needed to achieve convergence. After a period of time during which convergence is not possible, the brain tends to ignore the impulses received from the divergent eye. Light rays cause chemical changes in photosensitive pigments in these cells and they emit nerve impulses which pass to the occipital lobes of cerebrum via the optic nerves. The different wavelengths of light stimulate photosensitive pigments in the cones, resulting in the perception of different colours. In a bright light the light rays are focused on the macula lutea (photopic vision). It is bleached by bright light and when this occurs the rods cannot be stimulated. Rhodopsin is quickly reconstituted when an adequate supply of vitamin A is available. When the individual moves from an area of bright light to one of dim light, there is variable period of time when it is difficult to see. The rate at which dark adaptation takes place is dependent upon the rate of reconstitution of rhodopsin. In dim evening light different colours cannot be distinguished because the light intensity is insufficient to stimulate colour sensitive pigments in cones. Light Sense Light sense is the faculty which permits us to perceive light as such and in all its gradation of intensity. Light Minimum Light minimum is the minimum intensity of light appreciated by the retina. If the light which is falling on the retina is gradually reduced in intensity, a point comes when light is no longer perceived. Dark Adaptation Dark adaptation is the ability of the eye to adapt itself to decreasing illumination. If one goes from a bright light into a dimly lit room, one cannot perceive the objects in the room until sometime has elapsed. Form Sense Form sense is the faculty which enables us to perceive the shape of objects. Sense of Contrast Sense of contrast is the ability to perceive slight changes in luminance between regions which are not separated by definite borders. Colour Sense Colour sense is that faculty which helps us to distinguish between different colours as excited by light of different wavelengths. When red, green, and blue portion of spectrum mix together, they produce white colour. There is Absorption spectrum of three cone pigments absence of one or two of the photopigments normally found in foveal cones. Blue blindness occurs in sclerosing black cataracts which is said to affect the paintings of artists in old age. It is important to test colour vision in certain occupations like drivers, pilots, sailors, etc. There is an overlap in the middle but the left eye sees more on the left than can be seen by the other eye and vice versa. The images from the two eyes are fused in the cerebrum so that only one image is perceived. Binocular vision provides a much more accurate assessment of one object relative to another. Some people with monocular vision may find it difficult to judge the speed and distance of an approaching vehicle. The retina is divided into the temporal and nasal halves at the level of the fovea centralis. The nerve fibres from the nasal side of each retina cross-over to the opposite side. The nerve fibres from the temporal side do not cross but pass into optic tracts of the same side. They are cylindrical bands running outwards and backwards to end in the lateral geniculate bodies. They consist of the temporal fibres of the same side and the nasal fibres of the opposite side. The fibres of the optic tracts end in the lateral geniculate bodies and new fibres of the optic radiations originate from them. The neuron of the second order is the ganglion cell in the retina, the process of which pass along the optic nerve, optic chiasma and optic tract to the lateral geniculate body. The neuron of the third order takes up the impulses via the optic radiations to the occipital lobe (visual centre). Lesions of the occipital lobe often result in homonymous hemianopia with sparing of the fixation area.
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The nurses will be your first source of information about how your baby is doing symptoms 3 days past ovulation buy arava line, since they spend the most time with him or her medicine ball workouts purchase arava overnight. Having the same caregivers every day will allow the nurses to learn as much as possible about ichthyosis treatment conjunctivitis purchase arava without prescription, its special circumstances symptoms ulcerative colitis buy 20 mg arava free shipping, and how it affects your child medications hair loss discount arava 20 mg with mastercard. You have the right to limit the medical professionals who see your child to those who are immediately necessary symptoms xxy cheap 10 mg arava free shipping. You have the right to ask a doctor or technician to come back at a time when the baby is not sleeping. This is where dressing changes, baths, blood work, and other procedures took place. The staff purchased a brightly colored apron that they all wore during the painful procedures. The baby realized the difference and would recover quickly when placed back in her safe crib. This will offer a valuable bonding opportunity as well as help you prepare for your baby when he or she comes home. Remember, too, that these first weeks are a time for a mother to rebuild her own strength after the rigors of delivery. It helps no one if you allow yourself to become physically and emotionally drained. It is only natural that you might feel detached and even afraid to hold your baby. You must allow yourself, your spouse, and your family time to grow close to your new baby. Your baby is one of the few people who will never get tired of hearing your voice. In fact, your voice is so soothing to your baby, consider taping yourself reading or singing to comfort him or her while you are away. At last, I felt like she needed me and I was giving her something neither the specialists nor the machines could provide. Breast-feeding should not be ruled out because your child has ichthyosis or because he or she is in the hospital. It promotes optimum health because it provides specific immunities against illness, and proteins that enhance development. Breast-feeding also prevents over feeding and offers emotional rewards to both you and your baby. It can help you overcome the feeling of separation you may feel while your baby is in the hospital. Patience is important, for nursing comes naturally only to a lucky few; most moms and babies have to work at it for a while. Ask an experienced nurse for help, and if you continue to have trouble, consider seeking the help of a lactation specialist. Most hospitals will have one on staff who can help you, and if not, your doctor or nurse can recommend one. Regular pumping will also build up your milk supply for the day you are finally able to nurse. Sometimes the stress of having your baby in the hospital will prevent you from nursing effectively. Then, when your baby does come home, it may not be too late to begin nursing him or her. Millions of healthy babies have been raised with the bottle, and yours will do just fine. However, consult your physician about nutrition supple ments, such as iron, that may be helpful. Contact with these physicians gave you a good chance to evaluate specialists that you might turn to for long-term care for your child. At the same time, you are not bound to return to anyone for follow-up visits if your experience with them in the hospital was negative. As you evaluate specialists, keep in mind that most types of ichthyosis are very rare. You want doctors who have not only an academic, scholarly interest in medicine, but also clinical experience and a special interest in treating ichthyosis. These are the physicians who monitor medical journals, textbooks, scientific meetings, and pharmaceutical data to ensure that your child is benefiting from the latest and best research. Most important of all, you must feel that you can build a long-term professional relationship with the physician, one in which you are working together to manage a common problem. Or, you may want to contact an accredited medical school in your area for a list of names of faculty members who have dermatology practices in your community. A pediatric dermatologist is often a good choice because these sub specialists are used to caring for infants and children with skin diseases. A doctor who might be fine for teenagers with acne, or one who is solely a skin cancer specialist, may or may not have the professional curiosity and motivation necessary to monitor a complex disease in an infant. For many children with ichthyosis, additional time and attention to skin care will be the only medical issues that set them apart from 17 other children. Minor childhood diseases like chicken pox can be serious in a child with ichthyosis. Some children with ichthyosis cannot wear adhesive bandages because removing them tears the skin. Nutrition and growth can also be a significant secondary concern for your pediatrician and dermatologist to watch carefully. For most children with ichthyosis, physical, intellectual, and psychological development can be perfectly normal. Some forms of ichthyosis are associated with developmental delays, and in all forms of ichthyosis thickened skin blunts the touch sensation. Physical (motor and fine motor) and cognitive development, vision and eye control, and psychological well-being can all be affected by ichthyosis and require the support of a physician who is scholarly, yet practical, kind and compassionate without being maudlin, and accessible to you when you need advice. Federal and state funding is often available to help cover the costs of such things as delayed motor development, and a doctor can assist you in obtaining such aid. It is a good idea to encourage professional relationships between physicians caring for your child. A good dermatologist/pedia trician team will work together on such issues as diet, skin infections, chicken pox, stitches, casts, and other medical concerns that cross specialties where ichthyosis is concerned. Dermatology nurses, for example, can demonstrate effective ways to apply medications and dressings. Pediatric nurses often have great practical ideas for distracting a child during painful treatments. Nurses can interpret medical terms for you, help you get a doctor on the phone, and give you samples of medications they know you use. Depression can be a problem for people with ichthyosis, and may require intervention by a professional. Some parents find it helpful, especially for pre-teens and teenagers, to have a child or adolescent psychologist, or social worker, work through the emotional aspects of what can be a disfiguring condition. It is useful for 19 adolescents to have this kind of support from someone who is not a family member. I forced myself to push all my worries to the back of my mind and focus all my energy on our new baby. When we knew she was out of the woods, I started dealing with the hospital financial department and our insurance company. I was able, in most cases, to set up long term payment plans that fit into our budget. Children born with ichthyosis usually spend some time in the hospital, anywhere from a few days to a month or more. Since hospitalization will likely be in a neonatal intensive care unit, the costs can be astronomical. Additionally, throughout infancy and childhood, your child will probably require at least occasional, if not frequent, specialized medical attention. Learn about ichthyosis and give your attention to getting your child home, where you can create a warm, secure environment. Where unknowns exist (and there will be plenty of unknowns), make clear to policy administrators and insurance claims adjustors that some questions cannot be answered. The fact is, your health insurance carrier is probably unfamiliar with ichthyosis. In the course of filing claims, they will be evaluating unfamiliar medical circumstances to make reimbursement determinations. You may find that your insurance company occasionally (and perhaps frequently) does not allow coverage or reimbursement for various procedures and/or treatments. After your child is born, any change in employment that changes your insurance coverage may bring into play pre-existing condition exclusions. Some insurance companies deny coverage to those who need it most by refusing to insure anyone who has a pre-existing condition; that is, an illness or medical condition that existed prior to the application for coverage. However, studies show that the 21 uninsured receive fewer medical services and generally lower quality of care than people who are insured. Because assistance programs, as well as criteria to qualify for them, vary greatly from state to state, we cannot offer a blanket summary of programs. Make an appointment with a social worker at the hospital in which your child is being treated (or in your state of residence, if it is different from the location of the hospital). If no social worker is available there, contact your county or state Department of Health and Human Services. The department will be able to tell you where to go to learn about programs available to you and your child. Because coverage, once granted, becomes retroactive to the date of your first application for the program, it is important to begin the process as soon as possible. The process is frequently long and frustrating, but the benefits of coverage far outweigh the difficulties of the application and appeal. Two people with the same type of ichthyosis may have very different expressions of the condition and their response to the similar treatments may be very different as well. For instance, a lotion that works wonderfully for one child may be painful and even harmful for your child. Your dermatologist and pediatrician are, of course, excellent sources of information.
Circular design requires taking one step back treatment plan for anxiety arava 20mg mastercard, to rethink the function and the impact of the product before starting the actual design treatment deep vein thrombosis order arava 10 mg with visa. Hence medicine research cheap arava amex, it starts a fundamental discussion symptoms 2dp5dt buy arava cheap, and opens the floor for an entire new product design or proposition of services and a truly circular approach 911 treatment order 20mg arava with mastercard. Asking these kinds of questions is not part of the traditional chapter 9 medications that affect coagulation trusted 20 mg arava, more linear design approach, and still relatively new for companies. In that case, questions arise like: How we can we use more environmental friendly materials However the traditional eco-design is also integrating and stimulating the circular thinking to a greater extent. It will be done on basis of the eight strategies in the life-cycle of a product from the LiDs wheel. Replacing raw materials this step looks into the opportunities to replace harmful or energy intensive materials with for example recycled or renewable materials. The current status of the sector in using recycled and renewable materials is discussed in detail in chapter 5. Overall, it can be said that currently recycled materials are not being used due to health and safety issues. Renewable materials are used sporadically due to the economic costs and the technical requirements that the materials need to meet. Material efficiency the amounts of materials which are used in incontinence care products and diapers have been reduced significantly during the last years, thereby improving the environmental performance of diapers and incontinence products. In 1987 the average disposable baby diaper in Europe had a mass of 65 gram and 81% of this weight was fluff pulp. Between 1987 and 1995 the average weight of the product decreased with 14% and between 1995 and 2005 with another 27%. In recent years, the average weight decreased even further: by 12% between 2005 and 2011. Since the composition of average diapers did not change much in that period the further decrease in weight may be associated with the improved production and functionality of materials, components and layout of the product. It is expected that the reduction of weight will continue at a slower rate in the future. Process efficiency the production process of diapers and incontinence products have been optimized in recent years by minimalizing the required energy and inputs and generating limited amounts of manufacturing waste. Modern manufacturing processes also facilitate the production of lighter products. Optimizing distribution the sector has looked into optimizing its transport by more efficient packaging and transport modes. The reduction in weight of the diapers has also significantly contributed to minimalizing the environmental impact of transport. Heavier materials require more fuel to transport, so the lighter the diaper the lower the environmental performance. Optimisation use the performance of diapers and incontinence care products has increased significantly in recent years. As a results diapers and incontinence care products need to be changed less frequently than in the past. Nowadays diapers absorb urine much more efficiently, and are therefore still comfortable to wear even when lightly soiled. However, some work still needs to be done about the consumer perception, as often consumers do not realize that they do need change diapers that frequently anymore. Design for disassembly/recycling We could not find any examples in the literature, or in any of the interviews with the producers of single use diapers or incontinence care products that consider design for disassembly or recycling. The following reasons could be underlying to this: In most countries there is no separate waste collection for diapers and incontinence care products, and therefore no recycling schemes. Making any upgrades in the recyclability of the products not worthwhile at the moment. To design a product for high grade recycling, it needs to be completely clear which recycling will take the lead and what could changes in the design of diapers and incontinence materials could improve their recycling process. Probably, post-consumer recycling first needs to take place, starting collaborations throughout the value chain before design for recyclability can take off. We have found no examples in the literature, or in any of the interviews with the producers of single use diapers, or incontinence care products that fundamentally rethink the life expectancy or the function of the product. However reusable diapers and incontinency materials, which are washable, are of course an excellent example of increasing the life expectancy. The same can be said about modular design, with the current producers of single diapers and incontinency products there are almost no examples of modular design to be found. Especially since the absorbent cloths have a shorter live expectancy than the water proof cover. Below there is a short description of some interesting innovations, namely: Dry lock, Goodnites from Kimberly and Clark the Dry Max technology from P&G and the service model for diapers. Dry-lock36 Drylock Technology produces the first fully fluffless diaper and incontinence care products. The absorbent core is made of super absorbent polymer encapsulated between two layers. In general it can be said that products with less components are easier to disassembly or recycle. Despite the fact that the main reason for developing the Dry lock technology was not to facilitate easier recycling or disassembly this might well be the case. Goodnites37 In 2014 Kimberly and Clark has introduced Goodnites which are real washable cotton blend fabric underpants with super absorbent insert which can be replaced. Goodnites are training pants for children to potty train them during the night and are therefore not suitable for day-time and heavy soiling. This innovation is particularly interesting as it takes a modular design approach similar to the reusable diapers on the market such as g-Nappies but is initiated by Kimberly and Clark, a large producer of single-use diapers. In general, to change a market, acceptance and uptake of the major players in that market is needed. Dry Max technology38 In 2010, Procter & Gamble introduced the Dry Max line to the market with an absorbent gel that improved diaper efficiency while cutting materials and costs by 20%. The diapers were thinner thereby aiming to give more user comfort while also reducing cost and environmental impact. The innovation was so impressive that former president Bill Clinton praised it for reducing landfill waste. The interesting aspect of this innovation is the enormous consumer backlash it received. Consumers claimed that the new, thinner design resulted in more diaper rash and the thinner diapers were a low cost replacement other than an innovation. P&G had to put much effort into convincing their consumers that the new diapers were not to blame for the diaper rash. Partially due to higher material costs but also because of how they position themselves on the market. They tend to target environmentally conscious parents, who do not mind paying a small premium for environmentally and socially conscious products. In general eco-brands are more transparent when it comes to their materials (no hazardous chemicals/materials), offer more personalization (several prints can be selected) and provide a service model to deliver diapers on a monthly/weekly basis (gives bulk discount and extra convenience for the consumer). S: the Honest Company the Honest Company is a wellness brand that distinguishes itself on being environmentally and socially conscious and on the fact that their products do not contain any harmful materials. Consumers can get a monthly subscription40 service that bundles diapers and wipes together at better price and early access to new diaper designs. Parasolco Parasolco positions itself as eco-friendly design brand, which is sold via Amazon. The premium diapers and wipes, or diapers only are available only as a monthly subscription A drawback of the service models from the Honest Company and Parasolco is that they do not include the collection and recycling of the waste. As these brands distinguish themselves on sustainability it would be expected that they also look into the waste-collection aspect for a full R0 circular strategy. Patents on design innovations the manufacturers of absorbent hygiene products protect their technologies, even those not currently used with patents. A patent is valid for either 17 years from its issue date, or 20 years from the filing date of the earliest application. This means that the innovations cannot be used by other players in the sector for at least 17 years. It is likely that the high number of patents is a barrier towards circular economy transition of the sector. As one of the three drivers for a circular economy is technology innovation through a specific radically new technology (see paragraph 1. This inhibits an important driver for the circular economy transition, namely emergence of new technologies. Design for recycling needs to be a Set up roundtable of producers to joined effort of the entire sector as discuss opportunities for a joint effort as separate waste collection/recycling a sector on design for disassembly and for only one producer is not recycling. There is no dialogue between Set up dialogue between producers and recyclers and producers. As a recyclers to identify opportunities to result producers have no insight in improve recyclability. The outcomes of what is needed to improve this dialogue should be summarized recyclability and recyclers do not and shared through the sector. Diapers and incontinency materials Investigate the business case of Dry consist of various components. This is a limiting factor for Investigate opportunities with recyclability and disassembly. R2: Reduce will be discussed in chapter 5 and has also been discussed in chapter 3. A R0: refuse innovation has a very high impact but generally requires innovation in the core technology and socio institutional change. The most viable R0 strategy seems to be making diapers redundant by getting children to be toilet-trained earlier. This would save a large amount of diapers and has significant benefits for parents. The age that children are going to school has a significant influence on the average age at which they are toilet-trained (2. Stimulating toilet-training at an earlier age could reduce the use of single-use diapers. In Belgium children are generally toilet-trained at an early age, as they need to be able to use the toilet before they start nursery school at 2. However there is a growing percentage of children in Flanders who are not toilet-trained when they start nursery school. A study from the University of Antwerp42 shows that more than a third of the childcare workers feel that parents pass on their responsibility to toilet-train their child to the day-care personnel and that parents do not pay enough attention to toilet-training. More than 73 % of the nursery teachers stated that the opinions of parents on toilet-training have changed. Previous studies have showed that parents are less consistent and authoritarian and more liberal in their education. They are also short on time, mainly as a consequence of both parents working outside the home, which contributes to the postponement of the toilet training age. There are also some organizations saying that the introduction of disposable diapers increased the average age at which children are toilet-trained. They explain the increase in the average age by the fact that disposable diapers keep babies comfortable after they have used their diapers, thereby making children less inclined to be toilet trained. However, a study in Japan43 comparing two groups, one using cotton diapers and the other disposable diapers revealed that the time when they were toilet-trained was the same in both groups: the average was 27 months (6 months later than the average 20 years ago). In addition, the same study was performed with identical twins, one sibling using cotton and the other, disposable diapers. Also in the study with the identical twins, no difference was observed as to notice before discharge, notice after discharge, or period of use. A study from P&G45 also showed that cultural norms greatly influence the age at which a baby begins toilet training. High cloth diaper usage markets, such as India and China, tend to begin toilet-training babies when they are younger than 1 year. Russia, although predominately a disposable diaper usage market, also follows this practice of early toilet-training. In European countries, such as Germany, France, and the United Kingdom, as well as the United States and Japan, babies typically do not begin toilet-training until approximately 2 years old. However, if diaper type is really of influence can debated, especially with the newer, much more comfortable generation of reusable diapers. The most famous example of this approach is that consumers no longer buy the product but that they rent it as a service. The services such as Washcot 46 in Belgium and Tiny Tots 47 in the United States provides cotton diapers on weekly basis, collect them after use and wash them. When the cotton diapers reach their end-of-life, they are recycled or composted by the services. The services are available for both professional day-care facilities and consumers. The biggest disadvantage for consumers and day care facilities of the service model is the cost.
Nail problems I Wear gloves when washing dishes symptoms 7 dpo bfp order arava 10mg with mastercard, working in the garden symptoms 7dpo purchase 10 mg arava overnight delivery, or cleaning the house symptoms 0f low sodium proven 20 mg arava. Radiation recall I Protect the area of your skin that received radiation therapy from the sun 9 treatment issues specific to prisons cheap arava master card. Problems may include: I Burning or pain when you begin to urinate or afer you empty your bladder I Frequent medications similar to abilify arava 20mg amex, more urgent need to urinate I Not being able to urinate I Not able to control the fow of urine from the bladder (also called incontinence) I Blood in the urine I Fever I Chills I Urine that is orange symptoms joint pain fatigue purchase online arava, red, green, or dark yellow or has a strong medicine odor Some kidney and bladder problems will go away afer you fnish chemotherapy. Drink plenty of fuids if you are getting chemotherapy that can damage the bladder and kidneys. Your doctor or nurse will take urine and blood samples to check how well your bladder and kidneys are working. Flu-like symptoms may include: I Muscle and I Headache I Nausea I Chills joint aches I Fatigue I Fever I Appetite loss Tese symptoms may last from one to three days. Fluid retention Fluid retention is a buildup of fuid caused by chemotherapy, hormone changes caused by treatment, or your cancer. Sometimes fuid builds up around your lungs and heart, causing coughing, shortness of breath, or an irregular heartbeat. Fluid can also build up in the lower part of your belly, which can cause bloating. You and your doctor or nurse can help manage fuid retention by: I Weighing yourself at the same time each day, using the same scale. Some types of chemotherapy can bother your eyes and make wearing contact lenses painful. Ask your doctor or nurse if you can wear contact lenses while getting chemotherapy. Some types of chemotherapy can clog your tear ducts, which can cause blurry vision and watery eyes. If your vision gets blurry or your eyes water more than usual, tell your doctor or nurse. Soups I Bouillon I Clear, fat-free broth I Consomme Drinks I Clear apple juice I Clear carbonated beverages I Fruit-favored drinks I Fruit punch I Sports drinks I Water I Weak, cafeine-free tea Sweets I Fruit ices made without fruit pieces or milk I Gelatin I Honey I Jelly I Popsicles Soups I Cream soups I Soups with lentils, peas, or beans, such as garbanzo, pinto, black, red, and kidney Drinks I Instant breakfast drinks I Smoothies I Milkshakes I Whole milk Main meals and other foods I Beef I Cream cheese I Butter, margarine, or oil added to food I Croissants I Cheese I Deviled ham I Chicken I Eggs I Cooked dried peas and bean, such as I Fish lentils, garbanzo, pinto, black, red, and I Nuts, seeds, and wheat germ kidney I Peanut butter I Cottage cheese I Sour cream Sweets I Custards, sof or baked I Mufns I Frozen yogurt I Pudding I Ice cream I Yogurt, plain or vanilla Replacements and Supplements I Liquid meal replacements I Powdered milk added to foods, such as pudding, milkshakes, and scrambled eggs Main meals I Chicken or turkey, skinless I Cooked refned cereals I Cottage cheese I Eggs I Fish I Noodles I Potatoes, baked or mashed without the skin I White bread I White rice Fruits and vegetables I Asparagus I Bananas I Canned fruit, such as peaches, pears, and applesauce I Clear fruit juice I Vegetable juice Snacks I Angel food cake I Gelatin I Saltine crackers I Sherbet or sorbet I Yogurt, plain or vanilla Main meals I Baby food I Cooked refned cereals I Cottage cheese I Eggs I Macaroni and cheese I Mashed potatoes I Pureed cooked foods I Soups Sweets I Custards I Fruit, pureed or baby food I Gelatin I Ice cream I Milkshakes I Puddings I Smoothies I Sof fruits, such as bananas or peaches I Yogurt, plain or vanilla Diaper rash is usually a straightforward problem that can be cleared up easily, if the correct cause is found. Antibiotic ointment (triple antibiotic, bacitracin, or Neosporin non-prescription) applied 3 times a day usually clears this up quickly; you can safely try this as a home remedy. Both boys and girls can develop this, because yeast likes to live in wet, dark, warm areas. Yeast infections are treated with a prescription cream, which I usually prescribe during an office visit. If you have recently changed diaper brands, and a rash has developed within a few days, consider changing back to the old brand until the rash has cleared, then try another brand. For most cases of common diaper rash, try this procedure with every diaper change: 1. You might even consider putting the baby in the kitchen sink so that you can use the dish sprayer. Apply white zinc oxide diaper cream (such as Balmex or Desitin), so thickly (like cake icing) that a barrier is formed. The skin can heal under the layer of diaper cream, despite continued stooling and urination. It is important to prevent the spread of Germs called bacteria may cause infections. Antibiotics It is very important to carefully follow the instructions for taking the antibiotics. This means taking them on time and finishing the entire course of treatment, even if you feel better after a few days. Stopping the treatment early or skipping a dose could let the bacteria become more resistant. Then, put the cream or ointment on the other unused end of the cotton-tip swab, and apply the medicine inside the other nostril. Be sure to follow the interpreter the instructions for both antibiotics when you give them to your child. Washing Using Hibiclens soap (chlorhexidine gluconate solution 4%) Using a wash cloth, wash under arms, creases in groin or diaper area and bottom (avoid openings) with Hibiclens liquid soap, leaving on for a minute then rinsing off. Surveillance of Development: Play includes other chil dren; has fears about unexplained changes in environ Screening (See p 59. Water safety, car safety seats, outdoor health and safety Is your child speaking in sentences Attempt ophthalmoscopic exam of optic nerve Does unacceptable behavior elicit appropriate responses Observe for caries, plaque, demineral ization, staining, injury, gingivitis; language acquisition, Surveillance of Development: Has self-care skills (eg, speech clarity; adult-child interaction. How do acquisition, speech fluency/clarity, thought content/ parent, child, siblings interact Structured learning experiences, opportunities to socialize Do you have a favorite friend Are you scared that your partner or someone else may try to hurt you or your child Shows school readi Selective: Anemia; Lead; Tuberculosis ness skills: has mature pencil grasp, can draw a person with at least 6 body parts, prints some letters and 6 Year Visit numbers, is able to copy squares and triangles, has good Universal: Vision; Hearing articulation/language skills, counts to 10, names 4+ Selective: Oral Health; Anemia; Lead; Tuberculosis; colors, follows simple directions, listens and attends. Observe for caries, gingival inflamma tion, malocclusion; fine/gross motor skills, gait. Has anyone talked with you about activities and after-school programs, bullying, parental how your body will change during puberty Healthy weight, appropriate food intake, adequate calcium, How is your child doing in school How do you help your child water instead of soda, adequate physical activity in organized solve conflicts How well do you and your partner agree on how to talk with your child about sexual development and sexuality Inspect for acne, acanthosis nigricans, atypical fortably do youth and parent interact Who asks and nevi, tattoos/piercings, signs of abuse or self-inflicted answers most questions Examine Surveillance of Development: testicles for hydrocele, hernias, varicocele, masses. Calculate and Note: Beginning with the Early Adolescence Visits, many health care professionals conduct the first part of the medical interview with the parent in the examination room, and then spend time with the adolescent alone. This approach helps adolescents build a unique relationship with their health care professional, promotes confidence and full disclosure of health information, and enhances self-management. When explained within the context of healthy adolescent development, parents usually support this approach. Have you ever been touched in a way that made you feel uncom fortable or was unwelcome Inspect for acne, acanthosis nigricans, atypical comfortably do youth and parent interact Who asks and nevi, tattoos, piercings, signs of abuse or self-inflicted answers most questions Examine testicles for Surveillance of Development: hydrocele, hernias, varicocele, masses. Connectedness with family, peers, and community; Do you ever feel so upset that you wished you were not alive or interpersonal relationships; school performance that you wanted to die Were cal development, sexuality, gender identity (your identity as a male your partners male or female or have you had both male and or female), or sexual orientation What have you and your youth discussed about the risk limits/expectations about number of passengers, night of using alcohol/tobacco/drugs Do you have someone you can call for a ride if you feel unsafe riding with someone Inspect for acne, acanthosis nigricans, atypical How comfortably do young adult and parent, if present, nevi, tattoos, piercings, signs of abuse or self-inflicted interact Examine testicles for hydrocele, Surveillance of Development: hernias, varicocele, masses. Have you a plan so you can carry out your decisions about sex ever been hit, slapped, or physically hurt while on a date Were your part ners male or female or have you had both male and female part ners Source: See the Child Development theme inBright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,Third Edition. Tooth Eruption Chart Primary Dentition Permanent Dentition Upper Teeth Erupt Exfoliate Upper Teeth Erupt Central incisor 8-12 months 6-7 years Central incisor 7-8 years D. Second molar 12-13 years Third molar (wisdom tooth) 17-21 years Lower Teeth Erupt Exfoliate T.
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