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The focus of this counseling should be on the use of approved child safety seats, and following the instruction manual on the proper installation and use. They should be advised to not administer anything for the poisoning before calling the poison control center. Most importantly, they should be counseled on the proper storage of Page 34 medications, cleaning agents, household chemicals and toxins. Bottles for chemicals and household cleaners, or other potential toxins should not be reused for other things. An association exists between drowning and leaving a child less than 3 years old unattended in the bathtub. Evidence that a health provider can influence parental supervision of young children during bath time is limited (9). Still, parents should be cautioned of the dangers of leaving young children unattended around water, such as the bathtub, a bucket full of water or the swimming pool. Specifically, counseling should include example points such as attending to their infant in a bathtub is more important than answering the phone or the doorbell. Parents of older children may develop a false sense of security if their children have had swimming lessons and should be cautioned that their children still need to be supervised around water, since they are still at risk for drowning. In conclusion, there are multiple potential opportunities in the office and clinic setting for preventing injury and disease with caregiver guidance and teaching. A complete discussion of all the elements of anticipatory guidance at each age group is beyond the scope of this chapter. The American Academy of Pediatrics provides pediatricians with recommendations on anticipatory guidance counseling at each age group (1,10). True/False: For most problems caused by parental child rearing knowledge deficits, there is good evidence from high quality studies that physicians can change parental behavior through simple counseling in the primary care setting 2. True/False: the anticipatory guidance issues for two year olds are very different for boys as compared to girls. Do to the child what the child does to others so they learn why not to do certain things. True/False: Children can develop fluorosis by using fluoride toothpaste and fluoride supplements. True/False: Parents do not need to supervise their two year olds who have already completed swimming lessons. Children can be offered a variety of nutritious foods and be allowed to choose what to eat and how much. It is abnormal for children at this age to eat a lot for one meal, and not much the next. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.

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Hyperaminoacidemia (glutamine, alanine, and lysine) and hypercitrullinemia can be found but these require special tests. Tissue histopathology demonstrates microvesicular steatosis of the liver, kidneys, and brain. Page 602 Epidemics of Reye syndrome seem to occur during epidemics of influenza B virus. The use of salicylates (aspirin) is associated with Reye Syndrome, and therefore its use is contraindicated in children (acetaminophen or ibuprofen is usually recommended instead). The proposed pathological mechanism in Reye is mitochondrial damage caused by salicylate metabolites or some other toxin during a viral infection. Mitochondrial damage leads to elevated short chain fatty acids, hyperammonemia, and directly to cerebral edema. In very young children, metabolic defects in fatty acid oxidation may contribute to the pathogenesis. The diagnosis of Reye syndrome is based largely on clinical findings, after ruling out other causes of neurologic deterioration such as other encephalopathies, encephalitis, toxins, neoplasms, hepatic failure, fulminant hepatitis, fatty acid oxidation defects, other metabolic disorders, hemorrhage, etc. Histopathology and electron microscopy of a liver biopsy can be used to confirm the diagnosis, but this is usually not done clinically. Urine gas chromatographic analysis and serum acyl-carnitine levels will help to differentiate Reye Syndrome from metabolic disorders. In these patients, acyl-carnitine levels would be elevated, whereas they would be normal in patients with Reye syndrome. Patients with Reye syndrome will generally exhibit findings of cerebral edema and increased intracranial pressure. If the patient is in grade 3 coma (see below), mechanical ventilation may be necessary. Similarly, grades can be used as follows: Grade 1=Subject is able to obey simple commands. Grade 5=Autonomic dysfunction with hypothermia, cardiovascular instability and absent spontaneous respiration. Intracranial pressure should be monitored directly which is best done with a ventricular catheter and kept below 15-20 mmHg through the use of periodic mannitol infusions (0. Systemic blood pressure should be monitored and kept high enough to maintain cerebral perfusion pressure (the difference between mean arterial pressure and intracranial pressure) above 45-50 mmHg. Maintenance fluids using 10% glucose (to reverse hypoglycemia and to some degree as an osmotic agent) should be given at a rate sufficient to produce a urine flow of 1. Vitamin K, 3-5 mg intramuscularly, should be given to reduce the likelihood of coagulopathy due to vitamin K dependent factor depletion. Reye syndrome is a serious neurologic condition, but roughly 70% of patients with Reye syndrome survive.

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The anti-inflammatory and pro-surfactant properties of corticosteroids made them a logical focus of study. These and subsequent studies have repeatedly demonstrated the positive short term benefits of corticosteroids as manifested by dramatic weaning of ventilator and oxygen support. As with many clinical trials, dosing amount, frequency, and treatment duration varied widely among studies. Adverse side effects, including hyperglycemia and hypertension, have also been documented. Subsequent trials of early dexamethasone use (within the 1st week of life) have shown greater risk than benefit (6,7). Therefore, if dexamethasone therapy is being considered, its use should be reserved for those patients with established chronic lung disease or prolonged ventilator dependency, typically older than 1 week of age (8,9). Of great concern is evidence suggesting that dexamethasone treatment is associated with an increase in developmental disability and cerebral palsy. It is the knowledge of the many serious side effects associated with systemic dexamethasone that has prompted clinicians and investigators to consider the use of hydrocortisone and inhaled corticosteroids in the prevention and treatment of chronic lung disease. Inhaled corticosteroids have been used in the treatment of adult and childhood asthma for many years. Limited studies in neonates have demonstrated no significant benefit beyond a reduction in the need for systemic steroid therapy (10). Logistical issues surrounding dosing and drug delivery in infants has further complicated this matter. Inhaled steroids are safer, but not without serious systemic side effects, especially at higher doses. Despite the lack of clinical symptomatology in older children and adolescents, abnormalities often persist on pulmonary function testing. Less than 1% of ventilated preterm infants remain ventilator dependent for months or years. Aggressive measures to prevent and treat acute (respiratory) infections (hand washing, immunization, prompt use of antibiotics) must be instituted for an optimal outcome. The smallest preterm infants are at highest risk due to the anatomical and biochemical immaturity of their respiratory, antioxidant, and immune systems. Research is ongoing to further characterize the pathogenesis and explore safer and more effective options for prevention and treatment. All of the following factors are included in the pathogenesis of chronic lung disease except: a. For adequate growth, infants with chronic lung disease frequently require a caloric intake of: a. Controlled trial of Dexamethasone Therapy in Infants with Bronchopulmonary Dysplasia. Early postnatal (<96 hours) corticosteroids for preventing chronic lung disease in preterm infants. Moderately early (7-14 days) postnatal corticosteroids for preventing chronic lung disease in preterm infants.

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