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Avidin lotus herbals 4 layer facial purchase karela 60caps mastercard, a heat labile protein in egg white himalaya herbals nourishing skin cream order karela 60caps on-line, binds and prevents the absorption of biotin. Biotin is a coenzyme for several carboxylases involved in carbohydrate and fat metabolism. Deficiency symptoms include seborrheic dermatitis, alopecia, anorexia, glossitis and muscular pain. Spontaneous deficiency of biotin has been noted only in subjects consuming only raw egg white and in patients on total parenteral nutrition. Except for these unusual instances and rare genetic abnormalities of biotin dependent enzymes, there are no clearly defined therapeutic uses of biotin. Citrus fruits (lemons, oranges) and black currants are the richest sources; others are tomato, potato, green chillies, cabbage and other vegetables. It is partly oxidized to active (dehydroascorbic acid) and inactive (oxalic acid) metabolites. It directly stimulates collagen synthesis and is very important for maintenance of intercellular connective tissue. A number of illdefined actions have been ascribed to ascorbic acid in mega doses, but none is proven. Deficiency symptoms Severe vit C deficiency Scurvy, once prevalent among sailors is now seen only in malnourished infants, children, elderly, alcoholics and drug addicts. Symptoms stem primarily from connective tissue defect: increased capillary fragility-swollen and bleeding gums, petechial and subperiosteal haemorrhages, deformed teeth, brittle bones, impaired wound healing, anaemia and growth retardation. Anaemia: Ascorbic acid enhances iron absorption and is frequently combined with ferrous salts (maintains them in reduced state). Anaemia of scurvy is corrected by ascorbic acid, but it has no adjuvant value in other anaemias. No definite beneficial effect has been noted in asthma, cataract, cancer, atherosclerosis, psychological symptoms, infertility, etc. However, severity of common cold symptoms may be somewhat reduced, but not the duration of illness or its incidence. Improved working capacity at submaximal workloads has been found in athletes but endurance is not increased. Postoperatively (500 mg daily): though vit C does not enhance normal healing, suboptimal healing can be guarded against. It has also been found to accelerate healing of bedsores Chapter 68 Vaccines and Sera Vaccines and sera are biological products which act by reinforcing the immunological defence of the body against foreign agencies (mostly infecting organisms or their toxins). Vaccines impart active immunity-act as antigens which induce production of specific antibodies by the recipient himself. Antisera and Immune globulins impart passive immunity-readymade antibodies (produced by another person or animal who has been actively immunized) are transferred. Active immunization is more efficacious and longer lasting than passive immunization, but the former needs a latent period of one to many weeks, whereas the latter affords immediate protection. Acutely ill, debilitated or immunocompromised individuals may not be able to generate an adequate antibody response and require passive protection. Vaccines and sera are potentially dangerous products and mostly used in public health programmes-their manufacture, quality control, distribution and sale is strictly supervised by State health authorities. These biologicals are standardized by bioassay and need storage in cold to maintain potency. Vaccines are of 3 types: (i) Killed (Inactivated) vaccines: consist of microorganisms killed by heat or chemicals. They generally require to be given by a series of injections for primary immunization. The immunity is relatively shorter-lasting; booster doses are mostly needed at intervals of months or years.

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In urine herbals forum karela 60caps lowest price, phosphate is an effective buffer herbals for liver buy karela 60 caps otc, a function of its relatively high tubular concentration and pKa of 6. Maintaining normal phosphorus concentrations is essential for optimal cellular function. The kidney and (to a lesser extent) the small intestine are the main organs that maintain phosphorus homeostasis. A large proportion of dietary phosphate is absorbed from the gastrointestinal tract and excreted in urine. Transepithelial phosphate transport across intact intestinal epithelium is driven by an active sodium-dependent process. Compartmental analysis indicates that phosphate entering the cell across the brush border is transported through the cell and sequestered from the intracellular phosphorus pool. The form of phosphorus absorbed is not known, but both luminal pH and ionic strength determine the species available for absorption. Ubiquitination of target proteins tags them for removal from the cell membrane and for degradation in proteasomes. In the kidney, phosphorus homeostasis is regulated primarily via control of phosphorus reabsorption across the proximal tubule apical membrane. When levels of dietary phosphorus are normal and parathyroid function is intact, about 80% of filtered phosphate is reabsorbed. Urine (700 mg/day) Filtration (7,000 mg) Extracellular fluid Formation (250 mg) Bone Resorption (250 mg) Absorption (900 mg) Secretion (200 mg) Decreased dietary intake Phosphate-binding agents Alcoholism Diet (1,200 mg/day) Intestine Stool (500 mg/day) Figure 1 Phosphate fluxes and causes of hypophosphatemia. Dietary phosphorus intake, stage of growth and time of day contribute to the variability of fasting serum phosphorus concentrations. Hypophosphatemia is observed in approximately 2% of hospitalized patients,14 and can be related to decreased intestinal absorption of phosphorus, redistribution of phosphorus from the extracellular to the intracellular compartment, increased loss of phosphorus through the kidneys, or any combination of these processes. Decreased intake of phosphorus It is rare for decreased dietary intake alone to cause hypophosphatemia, probably because renal phosphate reabsorption is enhanced to compensate for decreased intake. On the other hand, malabsorption and phosphate binders can decrease intestinal phosphate absorption and result in hypophosphatemia. Acute respiratory alkalosis and metabolic alkalosis decrease serum phosphorus concentration. The reduction is much greater in respiratory alkalosis than in metabolic alkalosis of comparable severity. This mechanism stimulates the glycolytic pathway, specifically phosphofructokinase, a key rate-limiting enzyme of glycolysis. Production of sugar phosphates is enhanced, which in turn induces intracellular phosphorus entry, thus decreasing serum phosphorus concentration. This refractoriness is due to decreased pco rather than to the concomitant extracellular alkalosis. The proposed mechanism of hypophosphatemia in these patients is increased insulin release that causes an intracellular shift in distribution of phosphorus. Fiske was the first to call attention to this relationship between carbohydrates and serum phosphorus concentration. In addition to traditional, well known causes of this syndrome (inheritance, heavy metals, monoclonal gammopathy and metabolic disorders), new causative culprits are emerging, including antiretroviral medications (e. After 4 weeks of phosphorus repletion, all of these variables returned toward control values. The authors concluded that moderate phosphorus depletion can induce reversible changes in the composition of skeletal muscle and transmembrane potential in the dog. In hospitalized sufferers these factors can be compounded by alcohol withdrawal or alcoholic ketoacidosis.

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Pertussis is extremely contagious herbals online discount 60caps karela fast delivery, with attack rates as high as 100% in susceptible individuals exposed to herbalism order karela 60 caps otc aerosol droplets at close range. Although a person may be fully immunized, either actively or passively, the rate of subclinical infection is as high as 50%. Neither natural disease nor vaccination provides complete or lifelong immunity against reinfection or disease (1). Protection against typical disease begins to wane 3-5 years after vaccination and is unmeasurable after 12 years. In addition, pertussis incites histamine sensitivity, insulin secretion and leukocyte dysfunction. There are 3 post-incubation stages: 1) catarrhal, 2) paroxysmal, and 3) convalescent. After an incubation period from 3 to 12 days, the catarrhal stage is marked by: congestion, rhinorrhea, low-grade fever, sneezing, and lacrimation. As symptoms wane, the paroxysmal coughing stage begins which can be characterized by one or more of the following: 1) Intermittent, irritative hacking paroxysmal coughing, 2) Choking, gasping, eyes watering and bulging, 3) Occasional coughing up of mucous plugs, 4) Post-tussive exhaustion, 5) Coughing in long spasms with the face turning red, or sometimes blue. Conjunctival hemorrhages and petechiae on the upper body are common due to all the coughing, Pertussis should be suspected in a patient who complains of incessant coughing for 2 weeks, especially if nothing else shows up on the physical exam. Chlamydia trachomatis presents with purulent conjunctivitis, tachypnea, rales or wheezes. Leukocytosis (normal small cells, rather than the large atypical lymphocytes seen with viral infections) due to absolute lymphocytosis occurs in the late catarrhal and paroxysmal stages. Neutrophilia would suggest a different diagnosis or secondary bacterial infection. The chest radiograph shows perihilar infiltrates or edema and variable degrees of atelectasis. However, a false negative can occur in those who have received amoxicillin or erythromycin. A flexible swab kept in the posterior nasopharynx until the patient coughs, is one way to obtain the specimen. Those under 2 months of age have the highest reported rates of pertussis-associated hospitalization (82%), pneumonia (25%), seizures (4%), encephalopathy (1%), and death (1%). The principal complications of pertussis are: apnea, secondary infections (such as otitis media and pneumonia), and physical sequelae of forceful coughing. Coughing transiently increases the intrathoracic and intra-abdominal pressure resulting in conjunctival hemorrhages, petechiae on the upper body, epistaxis, hemorrhage in the central nervous system and retina, pneumothorax and subcutaneous emphysema, and umbilical and inguinal hernias. Page - 192 Reversible bronchiectasis or pseudobronchiectasis occurs commonly after pertussis. The bronchi may appear cylindrically dilated on bronchography, but usually resolved in about 4 months. Patients with significant respiratory infections should be hospitalized if they are less than 3 months of age, (other causes of pneumonia presenting during the first weeks of life include C. Other indications for hospitalizations include: severe coughing paroxysms, cyanosis, poor social support, or an infection in a high risk patient (prematurity, cardiac disease, chronic pulmonary disease, neuromuscular disorder, etc. Admission orders should include: Cardiorespiratory monitoring, continuous pulse oximetry, apnea monitor. Detailed cough records (cyanosis, tachycardia, bradycardia, presence of coughed up mucus plug; post-tussive exhaustion and/or unresponsiveness). Prn oxygen, stimulation, or suctioning (note: suctioning of nose, oropharynx, or trachea always precipitates coughing, occasionally causes bronchospasm or apnea, and should be done prn only). Medication order should include: erythromycin (estolate form preferred) 40-50 mg/kg/day div qid (max 2 g/day 24 hr) x 14 days. Nursing orders should include: Respiratory isolation for at least 5 days after start of erythromycin. Restricting visitation of coughing family members who might be spreading pertussis to others in the hospital (until they have taken erythromycin for 5 days). Management orders of household close contacts should include: Erythromycin, 40-50 mg/kg/day divided qid (max 2 g/day 24 hr) for 14 days to all household and close contacts, i. Hospital discharge criteria should include clinical improvement plus: no intervention required during coughing, adequate nutrition, absence of complications, and the parents are prepared for further home care. The vaccine currently used in the primary immunization series is a safer acellular vaccine composed of a suspension of inactivated B. It resulted in more frequent pain, swelling, erythema, and systemic reactions, such as fever, fretfulness, crying, drowsiness, and vomiting.

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Monitoring patients for pandemic influenza and instituting appropriate control measures Despite aggressive efforts to herbals for erectile dysfunction buy discount karela 60 caps on-line prevent the introduction of pandemic influenza virus herbals in india purchase karela 60caps on-line, persons in the early stages of pandemic influenza could introduce it to the facility. Residents returning from a hospital stay, outpatient visit, or family visit could also introduce the virus. Early detection of the presence of influenza in a facility is critical for ensuring timely implementation of infection control measures. If influenza symptoms are apparent, implement droplet precautions for the resident and roommates, pending confirmation of pandemic influenza virus infection. Patients and roommates should not be separated or moved out of their rooms unless medically necessary. Once a patient has been diagnosed with influenza, roommates should be treated as exposed cohorts. Cohort residents and staff on units with known or suspected cases of pandemic influenza. Consider routine use of surgical or procedure masks for all patient transport when pandemic influenza is in the community. If possible, place a procedure or surgical mask on the patient to contain droplets expelled during coughing. Oxygen delivery with a non-rebreather face mask can be used to provide oxygen support during transport. If needed, positive-pressure ventilation should be performed using a resuscitation bag-valve mask. When possible, use vehicles that have separate driver and patient compartments that can provide separate ventilation to each area. Notify the receiving facility that a patient with possible pandemic influenza is being transported. Follow standard operating procedures for routine cleaning of the emergency vehicle and reusable patient care equipment. Communication between home health care providers and patients or their family members is essential for ensuring that these personnel are appropriately protected. When pandemic influenza is in the community, home health agencies should consider contacting patients before the home visit to determine whether persons in the household have an influenza-like illness. Professional judgment should be used in determining whether to don a surgical or procedure mask upon entry into the home or only for patient interactions. Factors to consider include the possibility that others in the household may be infectious and the extent to which the patient is ambulating within the home. Outpatient medical offices Patients with non-emergency symptoms of an influenza-like illness may seek care from their medical provider. Implementation of infection control measures when these patients present for care will help prevent exposure among other patients and clinical and non-clinical office staff. Instruct symptomatic patients on infection control measures to limit transmission in the home and when traveling to necessary medical appointments. When influenza is in the region, these facilities should implement control measures similar to those recommended for outpatient physician offices. Anyone residing in a household with an influenza patient during the incubation period and illness is at risk for developing influenza. A key objective in this setting is to limit transmission of influenza within and outside the home. When care is provided by a household member, basic infection control precautions should be emphasized (e.

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Patients with absent factor H and factor I will have excessive consumption of C3; therefore herbals on demand shipping purchase 60 caps karela visa, those patients will have similar infections as those with C3 deficiency states herbals stock photos purchase 60caps karela fast delivery. There is no specific treatment for complement deficiency, except a purified C1 inhibitor preparation for hereditary angioedema due to C1 inhibitor deficiency. This protein is involved in the reorganization of the actin cytoskeleton in the cells. The initial manifestations often present at birth and consist of petechiae, bruises, bleeding from circumcision or bloody stools. The diagnosis can be made based on the manifestations and immunologic findings including low IgM, high IgA and IgE, poor antibody responses to polysaccharide antigens, moderately reduced number of T cells and variable depression of in vitro T cell function studies. Immunologic studies reveal combine immunodeficiency consisting of selective IgA and IgG2 deficiency, cutaneous anergy and depression of in vitro T cell function study. Hyper-IgE syndrome is characterized by chronic pruritic dermatitis, recurrent staphylococcal infections (skin and respiratory tract), markedly elevated serum IgE, eosinophilia and coarse facial features. The diagnosis may be difficult since there is no clear definition of high IgE levels and IgE levels may fluctuate from time to time. In addition, a high IgE level with eosinophilia is commonly seen in severe atopic dermatitis. Therefore, recurrent staphylococcal infections involving the skin, lungs and joints with other features including a distinctive facial appearance, dental abnormalities and bone fractures are essential for the diagnosis. Treatment with good skin care and continuous antimicrobial therapy such as trimethoprim-sulfamethoxazole are necessary. The defect leads to recurrent and uncontrolled catalasepositive organisms including S. The most common infections are lymphadenitis, abscesses of the skin, and of the viscera such as liver. Treatment includes short-term treatment of the infections, prophylactic trimethoprim-sulfa, recombinant human interferon-G (enhancing the production of reactive oxygen intermediates) and bone marrow transplantation. This condition is described in further detail in the chapter on neutrophil disorders. Killing of microbes is intact, but since the cells can not be mobilized to the point of inflammation and complement-mediated phagocytosis is impaired, the result is a lack of an inflammatory response. Histories of delayed separation of the umbilical cord, recurrent bacterial infections, necrotic skin lesions, severe gingivitis, periodontitis, and alveolar bone loss leading to early loss of deciduous and permanent teeth suggest the diagnosis. Treatment includes continuous antimicrobial therapy, good oral hygiene, white blood cell transfusions and bone marrow transplantation. Page - 156 Clinical Approach to Suspected Immunodeficiency the history should include the onset and type of the infections, the frequency, chronicity, severity and the responses to the previous treatments. The associated conditions such as failure to thrive, autoimmune disease, congenital anomalies and family history of consanguinity, fetal wastage and early childhood deaths should be noted. Infection with encapsulated bacteria such as Haemophilus influenzae type B, pneumococcus, etc. Complement Defects: Early complement deficiency: Sinopulmonary infection, autoimmune disease. Congenital agammaglobulinemia typically presents during the second 6 months of life when maternally transferred antibodies wane. Certain physical findings alert one to the possibility of primary immune deficiency. Failure to thrive secondary to recurrent infections is commonly seen in some antibody deficiencies and combined T and B cell deficiencies. Persistent sinopulmonary infections, especially ear drainage, pneumonia or bronchiectasis, are seen in antibody deficiencies, T and B cell deficiencies and complement deficiencies. Several congenital and hereditary conditions with musculoskeletal abnormalities are associated with immunodeficiency. These include Bloom syndrome, Fanconi anemia, trisomy 21, Turner syndrome, short-limbed skeletal dysplasia, cartilage-hair hypoplasia, Shwachman syndrome and ectodermal dysplasia.

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The appropriate balance between adult supervision and independent selfcare should be defined at the first interaction and reevaluated at subsequent visits rupam herbals buy generic karela 60caps online. Diabetes Self-management Education and Support Recommendation c c Youth with type 1 diabetes and parents/caregivers (for patients aged herbs names karela 60 caps discount,18 years) should receive culturally sensitive and developmentally appropriate individualized diabetes self-management education and support according to national standards at diagnosis and routinely thereafter. B c No matter how sound the medical regimen, it can only be effective if the family and/or affected individuals are able to implement it. A Providers should consider asking youth and their parents about social adjustment (peer relationships) and school performance to determine whether further intervention is needed. E Offer adolescents time by themselves with their care provider(s) starting at age 12 years, or when developmentally appropriate. As diabetes-specific family conflict is related to poorer adherence and glycemic control, it is appropriate to inquire about such conflict during visits and to either help to negotiate a plan for resolution or refer to an appropriate mental health specialist (18). Shared decision-making with youth regarding the adoption of regimen components and self-management behaviors can improve diabetes self-efficacy, adherence, and metabolic outcomes (21). Preconception counseling using developmentally appropriate educational tools enables adolescent girls to make wellinformed decisions (23). Screening Screening for psychosocial distress and mental health problems is an important component of ongoing care. It is important to consider the impact of diabetes on quality of life as well as the development S128 Children and Adolescents Diabetes Care Volume 41, Supplement 1, January 2018 of mental health problems related to diabetes distress, fear of hypoglycemia (and hyperglycemia), symptoms of anxiety, disordered eating behaviors as well as eating disorders, and symptoms of depression (25). These psychosocial factors are significantly related to nonadherence, suboptimal glycemic control, reduced quality of life, and higher rates of acute and chronic diabetes complications. Benefits of continuous glucose monitoring correlate with adherence to ongoing use of the device. B Automated insulin delivery systems improve glycemic control and reduce hypoglycemia in adolescents and should be considered in adolescents with type 1 diabetes. E c c the majority of children and adolescents with type 1 diabetes should be treated with intensive insulin regimens, either via multiple daily injections or continuous subcutaneous insulin infusion. B Continuous glucose monitoring should be considered in children and adolescents with type 1 diabetes, whether using injections or continuous subcutaneous insulin infusion, as an additional tool to help Current standards for diabetes management reflect the need to lower glucose as safely as possible. However, meticulous use of new therapeutic modalities, such as rapid- and long-acting insulin analogs, technological advances (e. Furthermore, studies documenting neurocognitive imaging differences related to hyperglycemia in children provide another motivation for lowering glycemic targets (2). Autoimmune Conditions Recommendation c Assess for the presence of autoimmune conditions associated with type 1 diabetes soon after the diagnosis and if symptoms develop. B Because of the increased frequency of other autoimmune diseases in type 1 diabetes, screening for thyroid dysfunction and celiac disease should be considered (48,49). Although much less common than thyroid dysfunction and celiac disease, other autoimmune conditions, such as Addison Table 12. A c c Screen individuals with type 1 diabetes for celiac disease soon after the diagnosis of diabetes by measuring IgA tissue transglutaminase antibodies, with documentation of normal total serum IgA levels or, if IgA deficient, IgG tissue transglutamine and deamidated gliadin antibodies. B Repeat screening within 2 years of diabetes diagnosis and then again after 5 years and consider more frequent screening in children who have symptoms or a first-degree relative with celiac disease. B Individuals with biopsy-confirmed celiac disease should be placed on a gluten-free diet and have a consultation with a dietitian experienced in managing both diabetes and celiac disease. B provided that further testing is performed (verification of endomysial antibody positivity on a separate blood sample). At the time of diagnosis, about 25% of children with type 1 diabetes have thyroid autoantibodies (51); their presence is predictive of thyroid dysfunctiond most commonly hypothyroidism, although hyperthyroidism occurs in ;0. For thyroid autoantibodies, a recent study from Sweden indicated antithyroid peroxidase antibodies were more predictive than antithyroglobulin antibodies in multivariate analysis (54). Thyroid function tests may be misleading (euthyroid sick syndrome) if performed at the time of diagnosis owing to the effect of previous hyperglycemia, ketosis or ketoacidosis, weight loss, etc. Subclinical hypothyroidism may be associated with increased risk of symptomatic hypoglycemia (55) and reduced linear growth rate.

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The availability of a community-based facility will be particularly important during a large outbreak (See also lotus herbals buy karela 60 caps mastercard. Much of the work in identifying and evaluating potential sites for isolation should be conducted in advance of an outbreak as part of preparedness planning herbals in the philippines generic karela 60 caps on-line. Each jurisdiction should assemble a team (including infection control specialists, public health authorities, engineers, sanitation experts, and mental health specialists) to identify appropriate locations and resources for community influenza isolation facilities, establish procedures for activating them, and coordinate activities related to patient management. Options for existing structures include community health centers, nursing homes, apartments, schools, dormitories, and hotels. An evaluation of the home for its suitability for quarantine should be performed, ideally before the person is placed in quarantine. For example, persons who do not have a home situation suitable for this purpose or those who require quarantine away from home (e. Ideally, one or more community-based facilities that could be used for quarantine should be identified and evaluated as part of influenza preparedness planning. The evaluation should be performed on site by a public health official or designee. No special precautions for removal of waste are required as long as persons remain asymptomatic. If an influenza pandemic begins outside the United States, public health authorities might screen inbound travelers from affected areas to decrease disease importation into the United States. If a pandemic begins in or spreads to the United States, health authorities might screen outbound passengers to decrease exportation of disease or implement domestic travel-related measures to slow disease spread within the United States. Because some persons infected with influenza will still be in the incubation period, be shedding virus asymptomatically, or have mild symptoms, it will not be possible to identify and isolate all arriving infected or ill passengers and quarantine their fellow passengers. Moreover, if an ill passenger is identified after leaving the airport, it might not be possible to identify all travel contacts within the incubation period. However, depending on the situation, these activities might slow the spread early in a pandemic, allowing additional time for implementation of other response measures such as vaccination. The value of compulsory restrictions in a setting of voluntary changes in travel patterns. Voluntary changes in travel will occur during a pandemic as persons may choose to cancel nonessential travel to decrease their potential exposure and risk of infection. In this context, the added value of compulsory restrictions should be considered relative to the societal disruptions that limitations on movement would cause. These strategies range from distribution of travel health alert notices, to isolation and quarantine of new arrivals, to restriction or cancellation of nonessential travel. Quarantine Stations are located at 20 ports of entry and land-border crossings where international travelers arrive. The effectiveness of these measures might be limited because asymptomatic travelers can transmit disease, travelers in the incubation phase might not become symptomatic until after arrival at their destinations, and it might not be possible to trace contacts within the incubation period for influenza. The ability to detect some cases early in the pandemic may slow disease spread even for a short time. Provide guidance on infection control procedures that can be implemented, if needed, on airplanes (e. Isolate arriving ill passengers or border crossers, and quarantine their contacts as necessary. The Federal government has primary responsibility for preventing international importation of diseases. Public Health Service authority for quarantine relates to international travel, as well as travel between states, to help prevent domestic disease spread.

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At the local level vaadi herbals order karela 60 caps amex, pediatricians are encouraged to herbals recalled purchase 60 caps karela fast delivery work collaboratively with the obstetric and nursing community, promote hospital policies and procedures to facilitate breastfeeding, and become familiar with local breastfeeding resources. At the community and national level, pediatricians can also work to reform insurance coverage of necessary breastfeeding services and supplies, promote breastfeeding education as a routine component of medical school and residency education, and encourage the media to portray breastfeeding as positive and the norm. What are some clinical indications that suggest inadequate or sub optimal breastfeeding? What can health care providers do to improve breastfeeding practices for their patients? Approximately 60% of women breastfeed immediately post-partum, 20% are still breastfeeding at 6 months, and less than 5% are still breastfeeding at 1 year. The Healthy People initiative set a target to increase the proportion of mothers who exclusively breastfeed to 75% at postpartum, 50% at 6 months, and 25% at 1 year. Advantages of breastfeeding include health, nutritional, immunologic, developmental, psychological, social, economic, and environmental benefits. The major disadvantages to breastfeeding include time and energy required of the mother, decreased paternal (father) participation, and lack of universal social acceptance of breastfeeding practices by the public. Anatomic and physiologic changes that occur in the breast include: a) differentiation of epithelial alveolar cells into secretory cells for milk production. Human milk contains lactose as the main carbohydrate source, high whey to casein protein ratio, and variable fat stores which are dependent on maternal diet. Formulas have variable carbohydrate source which include lactose, starch or other complex carbohydrates. Protein sources can also vary by formula type: casein, whey, soy or protein hydrolysate. Fat sources in infant formula can vary as well: triglycerides with long or medium chains, etc. Barriers to successful breastfeeding include: physician misinformation and apathy, insufficient prenatal breastfeeding education, inappropriate interruption of breastfeeding, early hospital discharge, and late hospital follow-up care. Indicators for inadequate breastfeeding include: less than 6 urinations per day and 3-4 stools per day by day 5-7 of life, decreased activity level, difficulty arousing, weight loss of greater than 15% of birth weight within the first week of life. Provide good breastfeeding education at the prenatal visit, be well educated on anatomy and physiology of breastfeeding, advocate for breastfeeding policies. Breast milk is considered to be the optimal nutrient for the term or near term infant as an exclusive source of nutrition during the first six months of life. As a supplement or substitute for breast milk when a mother cannot or chooses not to breast-feed. Infants whose mothers are infected with organisms known to be transmittable by human milk (e. Infants whose mothers are receiving medication or drugs that are excreted into human milk. The caloric content of most infant formulas closely approximates that of human milk at 2/3 kcal/cc (20 kcal/oz). Infants are often their own best regulators, thus variation with each feeding should be expected. During the first 6 months of life, infants require 95-115 kcal/kg/day; 8-12% of these calories should be derived from protein, 30-50% from fat and 40-60% from carbohydrates. If these nutritional requirements are met, an infant will typically gain 25-40 grams per day (30 grams = 1 ounce) in the first 3 months and 15-20 grams in the second 3 months. Infant formulas are designed to mimic the nutritional composition of human milk, but in reality they contain a number of differences in the protein, fat and carbohydrate content. Milk protein can be divided into two classes based on relative solubility in acid: whey (acid soluble) and casein (acid insoluble). The whey:casein ratio of human milk is 70:30 as compared to a ratio of 18:82 for cow milk. Triacyl glycerol is composed of a glycerol backbone with 3hydroxyl group esterified to fatty acids.


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