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As a result, the infants may not be able to successfully initiate nutritive sucking. Oral-motor skill development is integrally linked with increasingly complex tongue movements (Gisel et al. In the typical pattern of development, the tongue first moves liquids through a nipple in an anterior/posterior (in/out) pattern. The tongue moves chewable foods with a lateral (side to side) pattern over to the molar surface and back to the center, splitting and separating the food until it is ground down enough and recollected to swallow (Ayano et al. Range of movement increases to allow sweeping anteriorly, posteriorly, laterally, and with tongue tip elevation. Lack of appropriate and successful practice may result in the loss of previously acquired oral motor skills and/or failure to acquire more advanced skills. Factors Influencing Oral-Motor Skills In addition to appropriate and successful practice, other factors can also negatively influence oral motor skill development. Feeding and swallowing movements and behaviors are very complex and clearly involve much more than just activities in the mouth, throat, and stomach (Gisel, Birnbaum, & Schwartz, 1998). The sensory motor systems provide both the structural foundation and the sensory information that enable a child to practice and master oral-motor skills (Morris & Klein, 2000). Because the dynamic feeding process involves internal activities such as breathing, digestion, and elimination; structural alignment, control and sensory input are important from top to bottom. Structural Alignment In the clinical feeding lore, there is an old adage, ?If you want the lips, you must first get the hips, meaning that support for function in the mouth comes from structures below (Morris & Klein, 2000). Biomechanical alignment means that structures of the body are aligned to allow the most efficient muscular interaction. For example, when the pelvis is in a neutral position, the structures of the spine line up biomechanically. A neutral position of the pelvis not only makes sitting up straight much easier, but also provides the spinal alignment and base of support for the rib cage, shoulder girdle, and head position. Figure 1 depicts a typical head-forward position resulting from loss of the biomechanical alignment of the spine that in turn results in poor head-shoulder-trunk alignment. As a result, the jaw is depressed and food and liquid are often lost during meals because the tongue and jaw are not able to move as freely for oral-motor function compared to a head in a neutral position (Patrick & Gisel, 1990). Several studies have demonstrated that proper biomechanical alignment is associated with improved swallowing, feeding and speech functioning (Gisel, Schwartz, Petryk, Clarke, & Haberfellner, 2000; Hulme, Gallacher, Walsh, Niesen, & Waldron, 1987; Kumin & Bahr, 1999; Larnert & Ekberg, 1995). For example, muscles of the neck can function in several ways: 1) as respiratory muscles to assist with breathing, 2) as swallowing muscles, and 3) as postural muscles to help maintain head and neck alignment. These muscle groups learn to work together to maintain all of these functions (McFarland, Lund, & Gagner, 1994; Palmer & Hiiemae, 2003). However, when life sustaining activities, such as breathing, become more difficult, muscles will be recruited from other functions to complete the desired task. For example, when breathing is challenged, muscles of the neck are automatically recruited to help, impacting head alignment and swallowing control.

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An adolescent or adult with tuberculosis almost always is the source of infection for young children. If an adult source outside the school is identifed (eg, parent or grandparent of a student), efforts should be made to determine whether other students have been exposed to the same source and whether they warrant evaluation for infection. Children with erythema infectiosum should be allowed to attend school, because the period of contagion occurs before a rash is evident. Parvovirus B19 infection poses no risk of signifcant illness for healthy classmates, although aplastic crisis can develop in infected children and adults with sickle cell disease or other hemoglobinopathies. The relatively low risk of fetal damage should be explained to pregnant students and teachers exposed to children in the early stages of parvovirus B19 infection, 5 to 10 days before appearance of the rash. Exposed pregnant women should be referred to their physician for counseling and possible serologic testing. Infections Spread by Direct Contact Infection and infestation of skin, eyes, and hair can spread through direct contact with the infected area or through contact with contaminated hands or fomites, such as hair brushes, hats, and clothing. Lesions may develop when these organisms are passed from a person with infected skin to another person. Organisms also can be transmitted to open skin lesions in the same child or to other children. Although most skin infections attributable to S aureus and group A streptococcal organisms are minor and require only topical or oral antimicrobial therapy, person-to-person spread should be interrupted by appropriate treatment whenever lesions are recognized. Exclusion of any infected child with an open or draining lesion that cannot be covered is recommended. Infection is spread through direct contact with herpetic lesions or asymp tomatic shedding of virus from oral or genital secretions. Infection occurs through direct contact or through contamination of hands followed by autoinoculation. Topical anti microbial therapy is indicated for bacterial conjunctivitis, which usually is distinguished by a purulent exudate. Conjunctivitis attributable to adenoviruses or enteroviruses is self-limited and requires no specifc antiviral therapy. Spread of infection is minimized by careful hand hygiene, and infected people should be presumed contagious until symptoms have resolved. Except when viral or bacterial conjunctivitis is accompanied by systemic signs of illness, infected children should be allowed to remain in school once any indicated therapy is imple mented, unless their behavior is such that close contact with other students cannot be avoided. Fungal infections of the skin and hair are spread by direct person-to-person contact and through contact with contaminated surfaces or objects. Trichophyton tonsurans, the pre dominant cause of tinea capitis, remains viable for long periods on combs, hair brushes, furniture, and fabric. The fungi that cause tinea corporis (ringworm) are transmissible by direct contact.

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Caring for a Conscious Choking Adult or Child When to Call 9-1-1 If the choking person is coughing forcefully, let him or If the person continues to cough without coughing up the her try to cough up the object. A person who is getting object, have someone call 9-1-1 or the local emergency enough air to cough or speak is getting enough air to number. A conscious adult or child who has a completely blocked giving back blows and abdominal thrusts. A combination of 5 back blows abdominal thrusts and/or chest thrusts to clear the airway followed by 5 abdominal thrusts provides an effective requires a medical evaluation. Provide support by placing one arm diagonally Special Situations in Caring for the across the chest and bend the person forward at the Conscious Choking Adult or Child waist until the upper airway is at least parallel to the Special situations include: ground. Chest thrusts Stand or kneel behind the person and wrap your arms around his or her waist. Each back blow and abdominal thrust should be a separate and distinct attempt to dislodge the obstruction. Do not bend over anything with a sharp edge or corner that might hurt you, and be careful when leaning on a rail that is elevated. Alternatively, give yourself abdominal thrusts, using your hands, just as if you were administering the abdominal thrusts to another person (Fig. A Caring for a Conscious Choking Infant If you determine that a conscious infant cannot cough, cry or breathe, you will need to give a combination of 5 back blows followed by 5 chest thrusts. Use less force when giving back blows and chest thrusts to an infant than for a child or an adult. Breathing emergencies include respiratory distress, respiratory arrest and choking. Look for signals that indicate a person is having trouble breathing, is not breathing or is choking. When illness happens suddenly it can be hard to determine what is wrong and what you should do to help. I In this chapter you will read about the signals of sudden illnesses including fainting, seizures, stroke, diabetic emergencies, allergic reactions, poisoning and substance abuse. Checking the person also Unconsciousness or altered level of consciousness gives you clues about what might be wrong. However, Breathing problems when someone becomes suddenly ill, it is not as easy No breathing to tell what is physically wrong. At times, there are no Chest pain, discomfort or pressure lasting more signals to give clues about what is happening.

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If the Autoinjector does not reach room temperature, this could cause your injection to feel uncomfortable and it could take longer to inject. The front of your thigh or your abdomen except for the 2-inch (5cm) area around your navel are the recommended injection sites (See Figure D). Wipe the injection site with an alcohol pad in a circular motion and let it air dry to reduce the chance of getting an infection. Important: Do not touch the needle shield which is located at the tip of the Autoinjector below the Window area (see Figure A), to avoid accidental needle stick injury. If the Autoinjector is not used within 3 minutes of the cap removal, the Autoinjector should be disposed of in the sharps container and a new Autoinjector should be used. Place the needle-shield of the Autoinjector against your pinched skin at a 90 angle (See Figure H). To unlock it, press the Autoinjector firmly against your pinched skin until the needle-shield is completely pushed in (See Figure I). If you do not keep the needle-shield completely pushed against the skin, the green Activation button will not work. Keep the green button pressed in and continue holding the Autoinjector pressed firmly against your skin (See Figure J). If you cannot start the injection you should ask for help from a caregiver or contact your healthcare provider. Lift the Autoinjector straight off of the injection site at a 90 angle to remove the needle from the skin. The needle-shield will then move out and lock into place covering the needle (See Figure L). Do not touch the needle-shield of the Autoinjector, because you may stick yourself with the needle. If the needle is not covered, carefully place the Autoinjector into the sharps container to avoid any injury with the needle. There may be state or local laws about how you should dispose of used Autoinjectors. It may also be helpful to write any questions or concerns about the injection so you can ask your healthcare provider. Humira can be given as monotherapy in case of intolerance to methotrexate or when continued treatment with methotrexate is inappropriate (for the efficacy in monotherapy see section 5. Paediatric plaque psoriasis Humira is indicated for the treatment of severe chronic plaque psoriasis in children and adolescents from 4 years of age who have had an inadequate response to or are inappropriate candidates for topical therapy and phototherapies. Posology Paediatric population Juvenile idiopathic arthritis Polyarticular juvenile idiopathic arthritis from 2 years of age the recommended dose of Humira for patients with polyarticular juvenile idiopathic arthritis from 2 years of age is based on body weight (Table 1). Enthesitis-related arthritis the recommended dose of Humira for patients with enthesitis-related arthritis from 6 years of age is based on body weight (Table 2). Humira may be available in other strengths and/or presentations depending on the individual treatment needs. Paediatric plaque psoriasis the recommended Humira dose for patients with plaque psoriasis from 4 to 17 years of age is based on body weight (Table 3).