Although adoption is generally an elective decision initiated by the birth parents acne 1cd-9 order genuine aldara online, the birth parents often need support adjusting to the separation from their infant skin care while pregnant aldara 5percent online. American Academy of Pediatrics Committee on Fetus and Newborn; American Academy of Pediatrics Section on Surgery; Canadian Paediatric Society Fetus and Newborn Committee acne 7 year old boy purchase aldara australia. The American Academy of Pediatrics Committee on Environmental Health; Committee on Native American Child Health; Committee on Adolescence acne 50s discount 5percent aldara. Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation acne jokes 5percent aldara with mastercard. American Academy of Pediatrics Committee on Injury skin care names buy aldara amex, Violence acne 8 yr old girl buy aldara uk, and Poison Prevention and Committee on Fetus and Newborn acne light mask order aldara amex. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. American Academy of Pediatrics Committee on Early Childhood, Adoption, and Dependent Care. An evidence-based review of important issues concerning neonatal hyperbilirubinemia. Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. International Consensus Conference on Intersex organized by the Lawson Wilkins Pediatric Endo crine Society and the European Society for Paediatric Endocrinology. American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Task Force on Terrorism. The American Academy of Pediatrics Committee on Environmental Health; Committee on Substance Abuse; Committee on Adolescence; Committee on Native American Child. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. American Academy of Pediatrics Section on Breastfeeding; American Academy of Pediatrics Committee on Nutrition. Safe and healthy beginnings: a resource toolkit for hos pitals and physicians offices. Chapter 9 Neonatal Complications and Management of High-Risk Infants ^16^300 this chapter highlights some of the common complications encountered in the care of high-risk infants and, whenever possible, provides an evidence-based approach to management. Neonatal Complications Anemia Anemia of prematurity results from multiple factors and varies with the degree of immaturity, illness, postnatal age, and nutrition. Current evidence indicates that most cases of anemia that occur in the first 2?3 weeks after delivery mainly result from the volume of blood sampling obtained for clinical management. During growth, the balance of oxidative substrate (polyunsaturated free fatty acids), antioxidants (eg, vitamin E), and pro-oxidants (eg, iron) in the diet may play a role in red blood cell survival. As growth accelerates with advancing postnatal age, depletion of iron stores begins to affect erythropoiesis. A multipronged approach to decreasing red blood cell transfusion is recom mended, particularly in very low birth weight infants, to address both causa tion and correction of anemia of prematurity. This approach includes limiting blood sampling when possible, extensive use of noninvasive oxygen monitoring, optimal nutritional intake, adherence to a protocol with strict indications for transfusion of packed red blood cells, and establishment of a system of blood banking that limits donor exposure. Emerging evidence suggests that delayed cord clamping in preterm infants reduces the need for blood transfusion. Two studies have suggested that restrictive transfusion guidelines could be associated with adverse neurodevelopmental effects. Recombinant human erythropoietin, whether administered early in the neonatal course or initiated after several weeks, has demonstrated little utility in reducing the number of transfusions or the volume of transfused blood in clinical trials. Thus, routine use of human recombinant erythropoietin in preterm infants is not supported by current evidence. Neurologic immaturity of respira tory control is hypothesized to be a common underlying mechanism. Persistent apnea often is associated with inadequate oral feeding, which may be the only remaining issue to be resolved before discharge from the hospital. In the absence of objective measurements that clearly identify infants at risk of significant car diorespiratory instability, physicians have used an empiric approach of requir ing an event-free interval of some days before discharge. The precise number of days without apnea or bradycardia episodes that defines full maturation and diminished risk after discharge has not been determined. Home cardiorespi ratory monitors are rarely indicated for detection of apnea solely because of immature respiratory control and should not be used to justify discharge of infants who are still at risk of apnea. Home cardiorespiratory monitoring may be useful for some infants who are technology dependent (see also Hospital Discharge of High-Risk Infants later in this chapter). Neonatal Complications and Management of High-Risk Infants 323 Brain Injury Hemorrhagic and Periventricular White Matter Brain Injury Infants born at 32 weeks of gestation or less or who have birth weights of 1,500 g or less are at highest risk of hemorrhagic and other brain injuries. The vulner ability of the preterm infant arises from the vascular and cellular immaturity of the developing brain and may be compounded by inadequate cerebral autoregulation of blood flow during the frequent periods of physiologic insta bility characteristic of this group of newborns. Periventricular?intraventricular hemorrhage, the most frequent hemorrhagic lesion, ranges from a small germi nal matrix hemorrhage to varying amounts of intraventricular blood to massive intraparenchymal hemorrhage or hemorrhagic infarction. Most periven tricular?intraventricular hemorrhage occurs in the first 72 hours after birth. Posthemorrhagic hydrocephalus secondary to intraventricular hemorrhage often is apparent within 2?4 weeks after delivery, but can develop later. Periventricular leukomalacia is the most frequent white matter lesion identi fied. Residual lesions after brain injury include minimal to extensive cystic lesions in the periventricular white matter and ventriculomegaly secondary to diffuse cerebral atrophy. Porencephaly may develop after severe, localized isch emic or hemorrhagic infarction. These lesions evolve over the course of several weeks after the precipitating insult. Portable bedside cranial ultrasonography is the most frequent imaging modality used to diagnose and monitor the evolution of brain injury. The quality of the images is affected by the choice of equipment and the expertise of the ultra sonographer in obtaining consistent positioning of the sensor. It is recom mended that each center establish a protocol for screening cranial ultrasound examinations in infants who are at risk. Follow-up studies to monitor for the evolution of severity or emergence of a complication may be based on the clinical course and the initial findings. Although cranial ultrasonography is use ful in diagnosing and monitoring the development of posthemorrhagic hydro cephalus, this modality is poorly predictive of neurodevelopmental sequelae. Prenatal corticosteroids given to accelerate fetal lung maturation decreases the incidence and severity of periventricular?intraventricular hem orrhage. Postnatally, only prophylactic indomethacin has been documented to decrease severe periventricular?intraventricular hemorrhage in a large ran domized controlled trial; however, this decrease did not result in improved neurodevelopmental outcome at 18?21 months corrected age. No other post natal intervention has been found to consistently prevent either periventricu lar?intraventricular hemorrhage or other lesions, although many approaches have been tried. Hypocapnia has been associated with cystic periventricular leukomalacia and should be avoided. Hypoxic?Ischemic Encephalopathy Hypoxic?ischemic encephalopathy can be a neurologically devastating or fatal condition. Previous therapeutic interventions to ameliorate hypoxic?ischemic encephalopathy have failed to provide benefit; however, randomized trials of selective head cooling and whole-body cooling have demonstrated that mild hypothermia consistently results in a significant improvement in survival with out major neurodevelopmental impairment. The components of a hypothermia regimen include the criteria for inclusion, the timing of initiation, the length of cooling, the depth of hypothermia, and the type of cooling method. Thus far, infants with moderate to severe hypoxic?ischemic encephalopathy, as judged by the Sarnat criteria, and who are greater than 35 weeks of gestational age have been enrolled. Both selective head cooling and total body cooling have been successfully employed when instituted before 6 hours of postnatal age, with a target core temperature of 33?34?C (91. The usefulness of amplitude-integrated electroencephalography as an entry criterion is not yet clear. It is not known whether hyperthermia itself causes worse outcomes or whether infants destined to have worse outcomes also have hyperthermia as a manifestation of their disease. However, it seems prudent to take steps to avoid abnormally high temperatures in infants with hypoxic?isch emic encephalopathy. Ongoing and proposed trials of hypothermia may clarify issues, such as whether delayed institution of hypothermia is beneficial, whether deeper or longer hypothermia regimens can further improve outcomes, and whether amplitude-integrated electroencephalography is a useful and generalizable tool for decision making and outcome prediction. Until those results are available, practitioners should take care to institute therapeutic hypothermia only in a regimen similar to those used in published trials and only at institutions with practitioners who are trained in its use. Hyperbilirubinemia ^ Although bilirubin is toxic to the central nervous system, the factors that deter mine its toxicity in the infant are many, complex, and incompletely understood. They include factors affecting the serum albumin concentration, the binding of bilirubin to albumin and the penetration of bilirubin into the brain, as well as comorbidities, gestational age, postnatal age, and the vulnerability of brain cells to the toxic effects of bilirubin. The relationship of specific serum bilirubin concentrations to bilirubin encephalopathy (the clinical neurologic findings caused by bilirubin toxicity to the basal ganglia and various brainstem nuclei), either in the first weeks after birth (acute bilirubin encephalopathy) or as the chronic and permanent neurologic condition (kernicterus), is not clear. In addition, it is not known whether hyperbilirubinemia can result in chronic neurologic impairment less severe than that caused by kernicterus. Because of limited evidence and individual variations, it is difficult to provide recom mendations suitable to all situations. However, adherence to recommended practices is likely to reduce the risk of severe hyperbilirubinemia and associated adverse neurologic outcomes. Survivors may manifest serious sequelae, including athetoid cerebral palsy, hearing loss, paralysis of upward gaze, and dentoalveolar dysplasia. Although no specific total serum bilirubin threshold for neurotoxicity has been established, clinical observations of term infants with hemolytic disease indicate that clinical kernicterus is highly unlikely at unconjugated bilirubin concentrations of less than 20 mg/dL (342 micromoles per liter). Term and Late Preterm Infants Without Hemolytic Disease There are no properly designed studies, or even observational data, on term or late preterm infants without hemolytic disease on which to base clinical guidelines for the treatment of serum bilirubin concentrations of less than 20 mg/dL (342 micromoles per liter). Follow-up data for apparently healthy term infants with bilirubin concentrations as high as 25 mg/dL (428 micro moles per liter) show no apparent neurologic sequelae. However, historical data and subsequent studies have shown that a total serum bilirubin greater than 30 mg/dL (513 micromoles per liter) carries a decidedly higher risk of ker nicterus. Preterm Infants Kernicterus is rare in preterm infants, and it is controversial whether modest increases of total serum bilirubin result in encephalopathy. Although some observational studies have suggested that bilirubin levels less than or equal to 5 mg/dL (86 micromoles per liter) may cause neurodevelopmental impair ments, others have suggested that modest increases have no such effects. Some published guidelines for the management of jaundice in extremely preterm infants have suggested early phototherapy and exchange transfusion for biliru bin concentrations as low as 10 mg/dL (171 micromoles per liter); however, several studies have failed to confirm a relationship between serum bilirubin concentrations and later neurodevelopmental handicap at concentrations of less than 20 mg/dL (342 micromoles per liter). In a recent multicenter trial, the neurodevelopmental effects of aggressive phototherapy versus conservative pho totherapy were compared in almost 2,000 extremely low birth weight infants. Neonatal Complications and Management of High-Risk Infants 327 25 428 20 342 15 257 10 171 5 85 0 0 Birth 24 h 48 h 72 h 96 h 5 d 6 d 7 d Age Infants at lower risk (equal to or greater than 38 wk of gestation and well) Infants at medium risk (equal to or greater than 38 wk of gestation with risk factors or 35?37? Guidelines for phototherapy in hospitalized infants at 35 weeks of gestation or older. These guidelines are based on limited evidence, and the levels shown are approxi mations. The guidelines refer to the use of intensive phototherapy, which should be used when the total serum bilirubin level exceeds the line indicated for each category. Infants are designated as higher risk because of the potential negative effects of the conditions listed on albumin binding of bilirubin, the blood-brain barrier, and the susceptibility of the brain cells to damage by bilirubin. For well infants 35?37 6/7 wk of gestation, total serum bilirubin levels can be adjusted for intervention around the medium risk line. It is an option to intervene at lower total serum bilirubin levels for infants closer to 35 wk of gestation and at higher total serum bilirubin levels for those closer to 37 6/7 wk of gestation. It is an option to provide conventional phototherapy in the hospital or at home with total serum bilirubin levels 2?3 mg/dL (35?50 micromoles per liter) below those shown, but home phototherapy should not be used in any infant with risk factors. Exchange transfusion was per formed if intensive phototherapy failed to bring the bilirubin below 13 mg/dL for the lower weight group and 15 mg/dL for the higher weight group. In this 30 513 25 428 20 342 15 257 10 171 Birth 24 h 48 h 72 h 96 h 5 d 6 d 7 d Age Infants at lower risk (equal to or greater than 38 wk of gestation and well) Infants at medium risk (equal to or greater than 38 wk of gestation with risk factors or 35?37? These suggested levels represent a consensus of most of the committee but are based on limited evidence, and the levels shown are approximations. During birth hospitalization, exchange transfusion is recommended if the total serum bilirubin level increases to these levels despite intensive phototherapy. For readmitted infants, if the total serum bilirubin level is above the exchange level, repeat total serum bilirubin measurement every 2?3 hours and consider exchange if the total serum bilirubin level remains above the levels indicated after intensive phototherapy for 6 hours. The dashed lines for the first 24 hours indicate uncertainty because of a wide range of clinical circumstances and a range of responses to phototherapy. Immediate exchange transfusion is recommended if the infant shows signs of acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos, fever, or high pitched cry) or if the total serum bilirubin level is equal to or greater than 5 mg/dL (85 micromoles per liter) above these lines. If the infant is well and at 35?37 6/7 wk of gestation (medium risk), total serum bilirubin levels for exchange can be individualized based on actual gestational age. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of ges tation. Subcommittee on Hyperbilirubinemia [published erratum appears in Pediatrics 2004;114:1138]. Aggressive phototherapy did significantly reduce neurodevelopmen tal impairment in survivors (26% versus 30%), but this reduction was offset by an increase in mortality in infants weighing 501?750 g at birth (39% versus 34%). Breastfeeding and Jaundice Some evidence indicates that frequent breastfeeding (8?12 times per 24 hours) may reduce the incidence of hyperbilirubinemia in infants. Supplementing nursing with water or dextrose-water is not necessary and will not decrease serum bilirubin concentrations in healthy, breastfeeding infants. Breastfeeding significantly affects the level and duration of unconjugated hyperbilirubinemia compared with formula feeding, primarily in two ways: 1. Inadequate fluid intake?This condition most often occurs in the set ting of a primiparous or first-time breastfeeding mother with a late preterm infant. Inadequate milk production can result in weight loss of as much as 30% of birth weight over the initial 7?14 days of life, marked hyper bilirubinemia, and, rarely, kernicterus or death. It is likely that caloric deprivation and its effect on the enterohepatic circulation of bilirubin is more responsible for this result than dehydration itself. Proper educa tion and support of the mother, together with early and close follow-up after hospital discharge to evaluate the feeding process and the health of the infant, are essential to prevent adverse outcomes. If failure of milk production persists, infants should be evaluated, rehydrated as needed, and changed to infant formula. Breast milk jaundice?This condition is characterized by a persistence of physiologic jaundice beyond the first week of age. Breastfed infants commonly have serum bilirubin concentrations greater than 5 mg/dL (85. This persistent, mild unconjugated hyperbilirubinemia is caused by a factor in human milk, which is yet unidentified, that promotes an increase in intestinal absorption of bilirubin. Infants with jaundice that persists beyond the first week of life should be monitored to ensure that it is unconjugated hyperbilirubinemia, that the concentration of bilirubin is not increasing, and that other pathologic causes for jaundice are not present. This can be combined with phototherapy and will almost always result in a rapid decrease in serum bilirubin concentrations. The mother should be strongly encouraged to maintain lactation and should be provided a breast pump during the period of interrupted nursing. Dehydration and Hyperbilirubinemia Some infants who are admitted to the hospital with high bilirubin concentra tions also may be dehydrated and may need supplemental enteral formula or pumped breast milk, or intravenous fluid, or both. Sick very low birth weight infants receiving phototherapy may have increased evaporative water loss and require increased intravenous fluid intake, or environmental humidity, or both to compensate for ongoing losses. Routine increases in fluid intake are probably not warranted; however, the state of hydration should be carefully monitored. Clinical Assessment Physicians should ensure that all infants are routinely monitored for the devel opment of jaundice, and nurseries should have established protocols for the assessment of jaundice (see also Hyperbilirubinemia Screening in Chapter 8). In most infants with total serum bilirubin levels of less than 15 mg/dL (257 micromoles per liter), noninvasive transcutaneous bilirubin measurement devices can provide a valid estimate of the total serum bilirubin level. Laboratory Evaluation A noninvasive transcutaneous bilirubin measurement, or total serum bilirubin measurement, or both should be performed on every infant who is jaundiced in the first 24 hours after birth. The need for and timing of a repeat noninvasive transcutaneous bilirubin measurement or total serum bilirubin measurement will depend on the age of the infant and the evolution of the hyperbilirubi Neonatal Complications and Management of High-Risk Infants 331 nemia. If there is any doubt about the degree of jaundice, the noninvasive transcutaneous bilirubin or total serum bilirubin should be measured. Visual estimation of bilirubin levels from the degree of jaundice can lead to errors, particularly in darkly pigmented infants. Risk Assessment Universal predischarge bilirubin screening using total serum bilirubin or transcutaneous bilirubin measurements is recommended to assess the risk of subsequent severe hyperbilirubinemia. In addition, a structured approach to management and follow-up is recommended according to the predischarge total serum bilirubin or transcutaneous bilirubin measurements, gestational age, and other risk factors for hyperbilirubinemia. Follow-up All hospitals should provide written and verbal information for parents at the time of discharge, which should include an explanation of jaundice, the need to monitor infants for jaundice, and advice on how monitoring should be done. Clinical judgment that incorporates an assessment of the risk of hyperbilirubinemia needing treatment (predischarge risk zone and clinical risk factors) should be used to determine the need for a bilirubin measurement. Jaundice that persists beyond 2 weeks requires further investigation, including measurement of total and direct serum bilirubin concentrations. An increase of the direct serum bilirubin concentra tion always requires further investigation. Treatment There are two commonly used treatment options for neonatal hyperbilirubine mia. Commonly used phototherapy units contain daylight, cool white, blue, or special blue fluorescent tubes. Other units use tungsten-halogen lamps in different configurations, either freestanding or as part of a radiant-warming device. Fiber optic systems have been developed that deliver high-intensity light via a fiber optic blanket. The efficacy of phototherapy is influenced by the energy output (irradi ance) in the blue spectrum (measured in microwatts per centimeter squared), the spectrum of light source, and the surface area of the infant exposed to the light source. The irradiance of a unit should be monitored and bulbs changed as needed to maintain maximum energy output. It is acceptable to interrupt phototherapy during feeding or brief parental visits. Intensive phototherapy can be achieved by using blue lights, decreasing the distance of the source from the infant, and increasing the surface area exposed to the lights.
This is because Dextrose (5%) water has 6 calories per ounce skin care oils order discount aldara online, and colostrum has 18 calories per ounce skin care questionnaire order aldara cheap online. By consuming sugar-water acne 40 year old woman order discount aldara on line, the newborn fails to ingest two-thirds of the calories needed to ward off reabsorption of bilirubin skin care magazines order generic aldara from india. Effective breastfeeding management that relies on 8-12 feedings every 24 hours can reduce or prevent early-onset pathological jaundice (Janke acne on scalp buy discount aldara 5percent online, 2008) acne home treatments buy generic aldara canada. Jaundice that appears after the first 24 hours of life (after the first 48 hours in preterm infants) and does not exhibit a daily bilirubin increase of more than 5 mg/dl skin care 5 steps buy 5percent aldara with mastercard, and does not exceed a level of 12 mg/dl in healthy and term infants or 15 mg/dl in preterms acne pregnancy buy aldara with american express, with a duration of not more than one week in term infants and no more than two weeks in preterms, is referred to as physiological jaundice (Toruner & Buyukgonenc, 2012). It is thought that this maternal factor increases the reabsorption of indirect bilirubin in the intestinal tract. When breastfeeding is stopped for 2-3 days, the level of indirect bilirubin falls within 24-48 hours. When breastfeeding is resumed, the jaundice may increase slightly and last Breastfeeding After a Cesarean Delivery 137 for weeks but it will not reach the levels it had before breastfeeding was interrupted. Mothers should be informed about continuing to express milk during the period that breastfeeding is interrupted (Sivasl? Late onset breast milk jaundice develops 4 to 7 days after birth, peaking at 7-15 days. This condition is less common (Statewide Maternity and Neonatal Clinical Guidelines Program, 2009). Because the level of bilirubin causing kernicterus cannot be determined and varies according to the individual infant, deciding upon the time to begin phototherapy is difficult. Newborns are generally introduced to phototherapy when bilirubin concentrations rise higher than 18-20 mg/dL after the first 48 hours after birth. The recommendation for bilirubin levels of over 18-20 mg/dL is more frequent breastfeeding and phototherapy (Agarwal et al. Assessment of late-onset jaundice in a newborn is firstly based on an analysis of bilirubin levels, after which the baby is formula-fed for 24 hours followed by another bilirubin level analysis. Treatment with an immediate exchange transfusion is indicated if the infant has jaundice and shows signs of intermediate to advanced stages of acute bilirubin encephalopathy, with possible symptoms of lethargy, hypotonia, poor feeding and a high pitched cry, hyper alertness or irritability, hypertonia, arching, or retrocollis-opisthotonos, where the baby is obtunded or comatose, displays apnoea or seizures. In general, babies show more interest in feeding when they are alert or awake, although they might be drowsy. In the first few hours after birth, babies are usually awake and eager to be fed but they may later become sleepy and then remain sleepy until they are a day old. The nurse will advise that the mother wake and feed the baby every three hours even if the baby does not demand the feeding on its own. Particularly if there are medical concerns such as jaundice, it is important for the health of the baby that mother -led two-hour feeding schedules are set up. Many premature babies are born by cesarean and this situation is twice as hard on the mother, since she must cope with both the stress of recovering from surgery and with the problems of a premature infant. The powerful emotional and physical implications of these situations can prove to be overwhelming for some women. Because preterm babies are born without having completed their intrauterine growth, all of their systems are immature and thus prone to many problems. One of the issues that come up in the clinical environment is the feeding of preterm infants. Preterms begin to be fed by mouth when their sucking, cheek and tongue movements have developed, there is enough coordination so that the uvula moves up and back to close the nasopharyx and the epiglottis closes the glottis, esophageal action is able to bring the milk down into the stomach, and hiccup reflexes are present (Cavusoglu, 2011; Murray & Mckinney, 2006; Neyzi ve Ertugrul, 2002). In one study, compared to a control group in which feeding regulation was doctor-designed, premature infants encouraged to feed with oral nutritional pathways were 6 days earlier in making the transition to completely oral feeding (Kirk et al. Healthy infants weighing more than 1500 grams may feed orally in the first few hours after birth (Tengir & Cetinkaya, 2008). Babies at a gestational age of more than 32-34 weeks with normal sucking and swallowing reflexes can feed on a bottle/breast in the absence of a severe pathological condition. At the same time, the transition to bottle-feeding may prove to be too stressful for a preterm infant (Savaser, 2002). Oral feeding should be discontinued at the first sign of discomfort; the baby should not be allowed to get worse. In the case of babies that are unable to suckle, the use of a spoon may be tried in place of bottlefeeding to encourage babies to get used to the breast. However, sucking-swallowing and breathing coordination must be developed before bottlefeeding is initiated (Savaser, 2002). While the goals of enteral feeding are to reduce the incidence of hypoglycemia and hyperbilirubinemia and to enhance cerebral and somatic development, the objectives of making the transition into bottlefeeding are to ensure sucking, swallowing and breathing coordination and to create an adequate tolerance for nutrient intake so that healthy growth and development can be encouraged (Satar, 2001; Savaser, 2002). To conclude, nurses should be able to observe symptoms of nutritional deficiency in premature babies, manage an appropriate feeding schedule, watch for complications related Breastfeeding After a Cesarean Delivery 139 to nutrition, observe the effectiveness of caregiving in terms of feeding, as well as be able to determine and implement effective nursing interventions. Nurses should also never forget their role as nutritional educator and consultant to mothers and fathers before, during, and after feedings. These infants are at risk of being premature or smaller relative to their gestational age. Multiple births have climbed significantly in the last 25 years, achieving unprecedented numbers in twins, triplets and other higher order multiples. Contributing to these rising rates have been the trend to delay childbearing and the increased interest in infertility therapy and assisted reproductive technologies (Bowers et al. In multiple pregnancies, it is important to ensure that each of the babies get adequate care after birth. Any one of the infants may have problems that need immediate intervention (Cavusoglu, 2011; Kliegman, 2002). About 2% of twins are born with major structural deformities, a condition that is higher in prevalence in same-sex twins. The most frequently encountered abnormalities are cardiac malformations, neural tube defects, facial clefts, and gastrointestinal anomalies. The rate of cardiac defects and gastrointestinal anomalies in multiples is twice the rate for singletons. The striking incidence of congenital anomalies in all twins is almost exclusively related to the higher rate of anomalies in monozygotic twins (Bowers et al. Conjoined twins occur at a rate of 1/50,000 to 1/100,000 births, being three times more common in female fetuses than in male fetuses. Survival of conjoined twins is seen to be generally dependent on the extent of shared organs (Bowers et al. If twin infants have twin-to-twin transfusion syndrome (or feto-fetal transfusion syndrome), the donor twin of the transfusion suffers retarded growth, anemia, pallidity, hypovolemia and malnutrition. For this reason, these babies may have to be transferred to the intensive care unit. Parents first encounter with the newborn is an important step in their relationship. Parents need guidance in this process (Cavusoglu 2011, Kliegman, 2002, Bowers et al. It is important for the mother that she is nourished during the lactation period with a diet enriched with protein and calories, adequate fluids and plenty of rest. If care is taken to meet these requirements, the mother will generally have adequate milk for her babies because twins and triplets actually stimulate milk production. Breastfeeding two babies simultaneously will give the mother time to rest and engage in other activities. The mother must be guided in placing herself in an optimum position for breastfeeding. If the infants are being artificially fed, she should enlist the help of other members of the household at feeding times (Cavusoglu, 2011). The term growth refers to increases in body dimension and development to the changes and maturing of biological functions. Growth and development processes are slower or more rapid at various ages but they occur with continuity and follow a defined pattern (Kurul, 2011). In the first six months of infancy, growth is a continuation of rapid development, independent of the growth hormones of the intrauterine stage. Postanatally, long term protein and energy deficiency leads to malnutrition and growth retardation. This is also an important issue in infancy, which is a period of rapid growth (Gunoz et al. Because of the unique characteristics of the period of pregnancy, making sure that conditions are appropriate for the healthy birth of a baby of normal weight and length is relatively more important in this period compared to other periods in life (Neyzi ve Ertugrul, 2002). Babies will generally lose weight shortly after birth but then start to gain steadily and predictably. If the infant does not gain the weight it is expected to gain or instead loses weight, this is referred to as failure to thrive. Non-organic failure to thrive brings with it an increased risk of physical illness, continued growth retardation as well as cognitive and emotional disturbances (Jaffe, 2011; Jolley, 2003). Such conditions may involve the esophagus, stomach, small or large intestine, rectum or anus and are usually brought about by an incomplete development of the organ. Failure to thrive may also be caused by an absence or poor quality of available food. Underlying this may be economic factors in the family, parental beliefs and concepts of nutrition, or child neglect. Psychosocial issues arising from poor parent-child relations can also bring about failure to thrive. Failure to thrive is accepted as a diagnosis when infants and toddlers exhibit significantly less growth than expected (Krugman & Dubowitz, 2003; Sahin, 2002). For this reason, each child needs to be monitored and evaluated periodically from birth. In the first two weeks of the neonate, weight increase should be assessed at frequent intervals (once a week or more). The growth and development of the child should from then on continue to be monitored once a month until the 6th month, every three months from 6th months of age to a year, every six months from age 2 to age 6, and annually from age 6 up until adulthood (Neyzi & Ertugrul, 2002). Babies are usually weighed at birth and that weight reading is used as a reference for future well-baby check-ups. When the baby shows signs of poor weight gain, this requires a more comprehensive examination by the health professional. This will involve looking into the family history of height and weight as well asking questions about feedings, illnesses, and family routines. The diagnosis of failure to thrive is confirmed where there is a positive growth and a behavioral response to enhanced nutrition (Jolley, 2003; Krugman & Dubowitz, 2003). The team should make an assessment of feeding disorders and ideally comprise a pediatric dietician, a social worker, and a speech/occupational therapist. A team approach can provide a more comprehensive assessment of the family situation, which will ultimately be more effective in dealing with symptoms such as growth retardation. A focus on only the child may conceal other factors that may be largely contributing to the growth failure (Jolley, 2003). In the event that there is a physical cause of failure to thrive, such as a disorder of the swallowing mechanism or intestinal problems, a corrective intervention might reverse the condition. If there are environmental factors involved, the physician will advise as to how the parents can obtain sufficient food for the infant. Hospitalization or the need for a more nurturing home may be indicated in extreme situations (Bergman & Graham, 2005). When there is no physical defect, maternal education and emotional/ economic support systems are all effective in helping to prevent the syndrome (Sahin, 2002). Polycystic ovaries have been found in young girls before puberty, indicating that this might be a congenital condition. The use of oral contraceptives may help to restore and regulate menstrual function and hormone levels, as well as decrease acne and hirsutism (Grassi, 2008). The main objectives in treatment are menstrual function regulation, reduction of androgen and insulin levels, and improvement of dermatological symptoms (Grassi, 2008). Low volumes of glandular tissue may indicate a lack of ductile support for breastmilk production. In the control group, 89% were breastfeeding exclusively and 2% did not breastfeed. It was found that at three and six-months postpartum, breastfeeding was equal in the two groups. Another study came to the conclusion that maternal androgen levels in mid-pregnancy are negatively associated with breastfeeding (Carlsen et al. For this reason, breastfeeding women with the syndrome need additional emotional and clinical support. They should be strongly encouraged to breastfeed since they are usually able to carry this out successfully and it is highly beneficial for their infants (Vanky et al. Milk production can be maximized with frequent feedings with full drainage along with an adequate diet and drinking fluids. Setting up strategies for breastfeeding early on during pregnancy, accessing resources from local support groups, and working with a certified lactation consultant soon after delivery are beneficial. This percentage is above the target set (15%) by the World Health Organization (World Health Statistics, 2011). It is known that a cesarean delivery can affect the bonding between mother and baby and make it more difficult for the mother to accept her child (Yigit et al. It is believed that the rise in cesarean birth rates stems from such factors as the rise in the ages of pregnant women, the increase in the percentage of first deliveries, the anxieties of mothers and doctors about the delivery, the preference shown to giving birth at private hospitals, and the desire to choose the time of birth (Olds et al. These include the necessity for surgery, the risk of infection and hemorrhage, the relatively more painful process compared to normal delivery, the prolonged recovery time, problems with digestion and elimination, and the delayed return of the mother back to her normal life (Buyukkayac? Because of these factors, the mother sometimes has difficulty taking the baby into her arms to breastfeed. Mothers who have given birth by cesarean section are as capable of breastfeeding their infants as mothers who have had normal deliveries (Y? There is often a delay in the initiation of breastfeeding with cesarean mothers due to the fact that these mothers need extra time to recuperate and to feel well enough to nurse their babies. Breastfeeding can begin as soon as they can hold the baby when they are fully conscious and alert. Epidural anesthesia generally is generally effective in helping mothers to breastfeed their babies sooner and for longer periods than mothers who have had general anesthesia (Jonkers, 2005). Cesarean babies are likely to be drowsy and lethargic, particularly if the mother was kept under anesthesia for a prolonged period during labor. Breastfeeding in these circumstances 144 Cesarean Delivery will still be successful but the milk supply may take longer to come in compared to what would occur after a vaginal birth. The lethargic baby may need encouragement and stimulation to be alert during feedings, but this period of lethargy is usually quick to pass (Ahmed & Najib, 2010). The method used in breastfeeding should be observed and improvements made to help the mother take the optimum position for successful breastfeeding. It should be ensured that the mother will be able to breastfeed her child using the correct method on her own (Ilgaz, 2000; Ince, 2001; Savaser, 2001; Y? The effects of educating mothers on mother-and-baby and family health have been clearly demonstrated. Information and consultation made available to the mother to eliminate deficiencies of knowledge about baby care has proved to increase competence, boost parents self-confidence, reduce mothers anxieties, and contribute to the growth and development of the baby. Social support has been found to have a positive effect on the psychological and social adjustment of the parents as well as on the bond between mother and baby (Gagnon & Bryanton, 2009). Bonding is the process in which the baby has the tendency to feel closer to certain people and safer in their presence (Gorak, 2002; Murray & Mckinney, 2006; Sabuncuoglu & Berkem, 2006). It is inevitable and natural that the baby should develop a bond with the person fulfilling its needs, the one who loves, protects and cares for him/her-the mother (Soysal et al. Babies trust the person they bond to and they want to spend their time with her, feeling safe and happy, seeking that person out whenever there is a situation that provokes fear or discomfort. It is for this reason that the bonding concept in infancy includes all of the patterns of these emotions and behaviors (Soysal et al. The togetherness of the family and the baby is a high quality and effective relationship that starts in the prenatal period, increases as the fetus becomes more active, coming to a peak with the actual birth. The process of connection between the family and the baby is different for the mother and the father. Breastfeeding After a Cesarean Delivery 145 the period right after the birth is an emotional time in terms of mother-baby bonding. Mothers who have difficulty developing bonding behavior are observed to be indifferent and inhibited toward the idea of touching their babies. There are mothers who indicate that they feel distant and detached from their caesarean babies. Part of these feelings may have to do with the fact that the mother cannot be a part of the actual birthing process and therefore is the last person to hold and cuddle the baby. Others are so bothered by physical pain, grogginess and exhaustion that they are disappointed in not being able to feel particularly joyful and caring about the baby (Korte, 1998). The mother who willingly and lovingly nurses her child instills a feeling of trust in the baby. Goodfriend (1993) has shown that babies taken from their mothers into special care for one reason or another immediately after birth often experience slower development or a halt in development altogether, exhibiting a sad facial expression while not feeding and retreating from social contact (Soysal et al. Lastly, starting off on a positive mother-baby relationship after a cesarean helps to instill a feeling of trust in the child and forms the foundation for the development of a healthy personality in later life. Nurses and other health professionals working with newborns have important responsibilities in helping to initiate this relationship. The physical and psychological effects of cesarean birth have more of an impact on the mother compared to normal delivery. Besides the physical problems that may arise because of the surgical nature of the procedure, not being able to actively participate in the birth, being unable to see the baby immediately and the inability to take an interest in the infant are all factors that may riddle the entire experience of birth with negative feelings (Say? In one study, when mothers were asked when they felt love toward their baby, 41% responded during the pregnancy, 24% said at the delivery, 27% remarked in the first week after the birth, and 8% commented after the first week. Forty percent of first-time mothers noted that they felt nothing when they first held their babies in their arms. For this reason, evaluating the early reactions and emotions of mothers is important in terms of fostering a bond between mother and infant (Moehler et al.
Cognitive Behavioural Therapy A cognitive behavioural approach involves helping people Additional Evidence achieve their desired goals through specifying the steps the Royal College of General Practitioners guideline for required and systematically reinforcing progress acne hormones buy genuine aldara line. This approach is often incorporated with exer trials of advice on activity for acute and subacute low back pain cise and activity restoration interventions (Indahl et al acne jeans mens purchase aldara canada. However acne location discount aldara generic, the study did not differentiate between acute and chronic pain popula had numerous limitations acne fighting foods purchase line aldara. The participants had recurrent spinal tions or specifically reviewed the chronic literature and some of pain with pain scores of at least seven out of 10 and a history of the included studies involved people with specific conditions at least four episodes in the past 12 months acne 101e purchase genuine aldara online, thus limiting acne velocite buy aldara overnight delivery. All of the systematic reviews except Evans and generalisability of the results to all cases of acute low back pain acne quistes buy generic aldara pills. In addition skin care forum order 5percent aldara with amex, the distribution of different pain sites between the the van Tulder et al. Groups were over the past six months (and not validated) and there was little 50 Evidence-based M anagem ent of Acute M usculoskeletal Pain Chapter 4. Acute Low Back Pain difference between the two groups in the numerous psycholog facet joint injections that met their criteria; all involved pain of ical and physical measures. The study population comprised patients with acute or is insufficient evidence to support the use of injection therapy in subacute back and neck pain (duration not defined) with less acute, non-specific low back pain. Sick leave updated in 2001) of injection therapy for subacute and chronic and health care utilisation were the primary outcome measures low back pain also distinguished between three injection sites and at one year, the risk of long-term sick leave was reduced (soft tissue, facet joint and epidural). The authors concluded that none of the reduction in physician and physical therapy visits (p <0. There are no controlled studies testing the effectiveness of electrom yo Doran and Newell (1975) compared use of a corset for three graphic biofeedback in acute low back pain. Valle studies involved chronic pain patients (duration more than one Jones et al. After 10 weeks of treatment the massage group had there is no clear evidence that this applies specifically to low less severe symptoms (pain, numbness, tingling) and less back pain. A false sense of security, skin irritation and general dysfunction than the self-education group (p = 0. The study involved chronic low back pain and involves stroking or rubbing the patients with low back pain ranging from one week to 8 soft-tissues with the hands or a mechanical device. It does not Clinical Evidence (2002) reported two systematic reviews specify whether patients had pain radiation, however those (Furlan et al. M assage alone reduced pain more effectively outcomes but a possible beneficial effect compared to placebo. The combined massage, exercise and education the only one to specifically involve patients (n = 90) with acute group achieved significantly lower pain intensity and quality low back pain (less than two weeks duration). The results scores after treatment and at one month compared to the other showed that all three groups (massage, spinal manipulation and groups (p <0. The review found that these effects were similar ately after the end of the first session for pain and straight-leg to the effects for exercise and manipulation. Subjects had a mix of acute, subacute and chronic differences among groups in relation to pain, however the low back pain (m ore than three weeks but less than six manipulation group demonstrated significantly better function months). Allowed co-interventions included paracetamol and scores compared with the massage group. The > There are no controlled studies on the effect of traction for acute low back pain. The latter is a review of trials involving chronic low back pain only and therefore has been excluded > M ulti-disciplinary treatm ent in the workplace im proves return to from this update. One of these studies involved patients with acute low back pain however there is no indication whether the pain is non Topical Treatments specific (H ackett et al. There was no control group in this study and no signif versus placebo electroacupuncture and paracetamol (n = 37). There is insufficient evidence for the effectiveness of spiroflar hom eo pathic gel or crem ol capsici for treatm ent of acute low back pain. This study included mainly male patients with acute low back pain; there was no description of whether the pain was non-specific. At four weeks follow up, the control group had effects of traction, citing studies by van der H eijden et al. Treatment of acute low back pain and acute low back pain, a small sample size and the results with piroxicam: results of a double-blind placebo-controlled trial. A comparison of osteopathic spinal manipulation with standard care for patients by Herman et al. Growing body of evidence on massage as a treat ment for low back pain: recent studies and systematic reviews. Treatment of acute lumbosacral back pain with sions; usual activities avoiding bed rest; and bed rest. The diclofenac resinate: results of a double blind comparative trial versus costing analysis suggested that undertaking usual activities and piroxicam. A double-blind study of cyclobenzaprine and although the Cochrane reviewer suggested the results should be placebo in the treatment of acute musculoskeletal conditions of the interpreted with caution as there were only 50 to 60 people per low back. At four weeks the manipulation group had low back pain and sciatica in the United States: treatm ent less pain and at 12 months there was very little difference outcomes. Acute low back pain therapy, it was unlikely to be cost effective to refer for manipu in industry: a controlled prospective study with special reference lation or M cKenzie therapy. Tizanidine and ibuprofen in acute low back pain: results of a double-blind multicentre study in (comprised of four therapist-led one hour exercise classes over general practice. Published data is very lim ited; however there is som e evidence that Blomberg S, Hallin G, Grann K, Berg E, Sennerby U (1994). M anual advice to m aintain usual activities, provision of an education booklet therapy with steroid injections a new approach to treatment and com m unity-based exercises appear to be cost effective first line of low back pain: a controlled multicenter trial with an evaluation interventions for acute low back pain. Epidemiology, etiology, diagnostic evalu antirheumatic: a randomised controlled study. The efficacy naproxen versus naproxen alone in the treatment of acute low back and tolerability of an 8-day administration of intravenous and oral pain and muscle spasm. Current M edical Research m usculoskeletal conditions: thoracolum bar strain or sprain. Chiropractic technique procedures for specific low back minophen in the treatment of patients with osteoarthritis of the conditions: characterising the literature. Clinical course and prognostic risk factors in acute low back treatment in patients with non-specific neck or low back pain. Comparison of diflunisal and acetaminophen with codeine in the M ulti-centre trial of physiotherapy in the management of sciatic treatment of initial or recurrent acute low back pain. Outcome of low back pain in general practice: a prospective Information and advice to patients with back pain can have study. The outcomes and costs of care for acute low back pain British M edical Journal, 313: 321?325. New England Journal of M edicine, 333: Evidence for use of an extension-mobilisatoin category in acute low 913?917. Cancer as a cause of back pain: frequency, provision of an educational booklet for the treatment of patients clinical presentation and diagnostic strategies. Journal of the back pain: a control group comparison of behavioural vs traditional American M edical Association, 268: 760?765. Journal massage vs Swedish massage and individual exercise vs group exer of Epidemiology and Community Health, 55: 455?468. Forsch Komplementarmed Klass Naturheilkd, 7: 2860293 of centralisation of lum bar and referred pain. Selective criteria m ay increase lum bosacral spine Dreyfuss P, Dreyer S, Griffin J, Hoffman J, W alsh N (1994). The role of fear-avoidance Dreyfuss P, M ichaelsen M, Pauza K, M cLarty J, Bogduk N (1996). The and symptoms as a screening tool for return to work in patients Physician and Sportsmedicine, 29: 37?43. Sudden unexpected deaths from Fukui S, Ohseto K, Shiotani M, Ohno K, Karasawa H, Naganuma Y ruptured abdominal aortic aneurysms. Distribution of referred pain from the lumbar zygapophy Forensic M edicine, 4: 111?116 seal joints and dorsal rami. Acupuncture for back pain: a meta-analysis Controlled comparison of shortwave diathermy with osteopathic of randomized controlled trials. British controlled trial of flexion exercises, education, and bed rest for M edical Journal, 291: 791?794. M edical Journal of Australia, 1: compared with paracetamol for acute low back pain. Journal manipulation as adjunctive therapy for acute low back pain: a strati of Bone and Joint Surgery, 35A: 981?987. Journal of the Canadian Chiropractic Association, 45: a light mobilization program reduce long-term sick leave for low 26?34. Stress reactions of the lumbar pars interarticularis: the of Bone and Joint Surgery, 83: 789. British Journal of lum bosacral nerve root anom alies by m agnetic resonance of General Practice, 52: 475?480. Cauda equina syndrom e differences between intervention programs on neck, shoulder and in patients undergoing manipulation of the lumbar spine. Spine, low back pain: a prospective randomised study among home-care 17: 1469?1473. Platt K, efficacy of a risk factor-based cognitive behavioral intervention and Hoehler F, Reinsch S, Rubel A (2002). Effectiveness of four conser electromyographic biofeedback in patients with acute sciatic pain: vative treatments for subacute low back pain: a randomised clinical an attempt to prevent chronicity. Functional of the effects of a placebo chiropractic treatment with sham outcomes of low back pain: comparison of four treatment groups adjustm ents. International Journal of an educational pamphlet to prevent disability after occupational of Rehabilitation Research, 21: 29?40. Long-term effectiveness of bone-setting, light exercise questionnaire for predicting 1-year follow-up in patients with low therapy, and physiotherapy for prolonged back pain: a randomized back pain? Quality of life and cost of care of back pain technique in acute low back pain: a preliminary investigation. Second prize: the effectiveness individual non-steroidal anti-inflam m atory drugs: results of of physical m odalities am ong patients with low back pain a collaborative m eta-analysis. A randomised controlled trial of transcutaneous electrical nerve Indahl A, Velund L, Reikeraas O (1995). Prognostic factors for return Hernandez-Reif M, Field T, Krasnegor J, Theakston H (2001). M agnetic resonance imaging of the is not automatic after resolution of acute first episode low back lumbar spine in people without back pain. Evaluation and management of occupational low active as a single treatment for low back pain and sciatica. On the distribution of pain arising from deep a screening tool for return to work in patients with acute low back somatic structures with charts of segmental pain areas. A double-blind placebo Kendrick D, Fielding K, Bentley E, Kerslake R, M iller P, Pringle M controlled study of piroxicam in the management of acute muscu (2001). 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A prospective study of the effects of sexual or physical European Journal of Physical M edicine and Rehabilitation, 4: abuse on back pain. Journal of O ccupational Clinical guidelines for the management of low back pain in primary Rehabilitation, 11: 53?66. Controlled A randomized trial of a cognitive-behavioiur intervention and two trial of balneotherapy in treatment of low back pain. Effectiveness and the effects of an early intervention on acute musculoskeletal pain cost-effectiveness of neuroreflexotherapy for subacute and chronic problems. Preventive interventions for back M cIntosh G, Frank J, H ogg-Johnson S, H all H, Bom bardier C and neck pain problems: what is the evidence? Low back pain prognosis: structured review of the litera Little P, Roberts L, Blowers H, Garwood J, Cantrell T, Langridge J, ture. A randomized controlled facto resonance imaging in low back pain instead of plain radiographs: rial trial of a self-management booklet and doctor advice to take experience with first 1000 cases. Loisel P, Gosselin L, Durand P, Lemaire J, Poitras S, Abenhaim L Descriptions of Chronic Pain Syndromes and Definitions of Pain (2001). British Journal of Clinical Loisel P, Vachon B, Lemaire J, Durand M J, Poitras S, Stock S, Tremblay Practice, 38: 107?109. Discriminative and predictive validity assessment of the M ilgrom C, Finestone A, Lev B, W iener M, Florman T (1993). Can a back pain e-mail discussion group improve health of Spinal Disorders, 6: 187?193. Archives M ilne S, W elch V, Brosseau L, Saginur M, Shea B, Tugwell P, W ells G of Internal M edicine, 162: 792?796. Journal of Occupational of osteopathic manipulation in non-specific low back pain. Randomised controlled trial of exercise in clinical manual lumbar spine examination. Physical Therapy, 74: for low back pain: clinical outcomes, costs and preferences. Prescription of activity for M ohseni-Bandpei M A, Stephenson R, Richardson B (1998). Australian Journal of Physiotherapy, 45: manipulation in the treatment of low back pain: a review of the 122?132. International Journal of Rehabilitation Research, 24: M ooney V, Robertson J (1976). Treatment of mild to Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V, Hernberg moderate pain of acute soft tissue injury: diflunisal vs acetamino S (1995). Back pain and sciatica: controlled trials of manipu lation, traction, sclerosant and epidural injections. Variance in the measurement of sagittal lumbar spine range of motion among examiners, subjects, and instruments. Commonwealth of Australia: M cGuirk B, King W, Govind J, Lowry J, Bogduk N (2001). Osteopathic medicine in the Prognostic factors for time receiving workers compensation benefits treatment of low back pain (Letter to the Editor). Spine, 19: Intertester reliability of judgements of the presence of trigger points 2571?2577. Psychosocial differences gluteus medius: a prospective study in non-specific low back pain in high risk versus low risk acute low back pain patients. Scientific Review of Alternative W illiams and M cKenzie protocols in back pain management. M anipulation in treatment of low back pain: Onorato A, Rosin C, Schierano S, Zampa A (2001). A critical review of the evidence for a pain-spasm pain cycle in spinal disorders. Current Combination hydrocodone and ibuprofen versus combination Therapeutics Research, 34: 917 928. Am erican Fam ily Physician, 61: 1779?1786, for back pain: a randomised controlled trial. Acute and chronic effects Legrand E, Valat J, Blotman F, M eadeb J, Rolland D, Hary S, of pneumatic lumbar support on muscular strength, flexibility and Duplan B, Feldman J, Bourgeois P (2002). 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Syndromes
Chronic sinusitis
Have severe pain, redness, swelling, or fever
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Injury from falls
Tremors
The first treatment is to place warm compresses over the eyelid for 10-15 minutes at least four times a day. Use water that is no hotter than you can leave your hand in comfortably. This may soften the hardened oils blocking the duct, and promote drainage and healing.
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Physical activity has not been found to result in weight loss beyond what you can achieve from reducing food intake (Foreyt et al skin care routine for acne buy aldara online pills. However acne 3 weeks pregnant buy aldara 5percent amex, physical activity can beneft your mental health in general skin care 2 in 1 4d motion discount aldara online american express, and your satisfaction with your body in particular skin care logos buy aldara 5percent low cost. In fact acne 11 year old boy purchase aldara online, one of the most exciting and growing bodies of research is the study of the impact of physical activity on mental health (Stathopoulou et al acne 12 weeks pregnant generic 5percent aldara overnight delivery. Physical activity was found to signifcantly reduce depressed mood and anxiety (particularly panic disorder) skin care 2 in 1 4d motion aldara 5percent generic, reduce cravings and increase abstinence rates in alcoholism acne location meaning discount aldara 5percent with amex, and reduce binge eating in people suffering from eating disorders (both bulimia and binge-eating disorder). Mental Health Benefts of Fitness Checklist Take a look at the following mental health benefts and make a check mark next to those that are of value to you. Take a look at the physical and mental health benefts of being physically active that you checked off on the previous list. My Personal Reasons to Improve My Fitness Level Now that you have recorded your reasons for wanting to increase your physical activity, we will describe the components of physical activity and ask you to rate your current level of physical activity. We will help you identify the types of activity that you will enjoy or at least fnd easy to ft into your life, even if you still have doubts that you can do it. Janice had dabbled in activity but had had diffculty maintaining anything she started because of her travel. There are three types of physical activity that signifcantly improve ftness: Cardiovascular (?Cardio) or Aerobic Activities Cardio activities include those in which your whole body moves continuously, often in a rhythmic manner, over a long period. Examples of cardio activities are brisk walking, jogging, running, swimming, 83 the Cognitive Behavioral Workbook for Weight Management and biking. Ideally, you will engage in some kind of cardio activity three to six times a week, giving your self a day off to allow your muscles to recover. For example, you may walk ten minutes to the bus stop in the morning, go on a twenty-minute walk at lunch, walk ten minutes from the bus stop home after work, and walk the dog for twenty minutes when you get home in the evening. The total daily time recommended for cardio activities ranges from twenty to sixty minutes. Almost all the physical and mental health benefts have been found for people who are active four to fve days per week, at moderate to high intensity. Muscular Strength or Resistance Activities Strength training includes any activity that requires pushing or pulling with effort, either with machines or free weights, or in the form of exercises using your own body weight, such as push-ups, squats, and sit-ups. Strength training can be built into your daily life through such things as yard work, carrying children or groceries, scrubbing tubs, or vacuuming carpets. If you are looking for a signifcant increase in muscle size, you have to push, pull, and lift weights so heavy that you can?t maintain good form (or posture) after eight to twelve repetitions. You will likely need a personal trainer to make sure that you are balancing the muscle groups correctly and maintain ing good form. If you are aiming for toned but not bulky muscles, you will choose lighter loads and do more repetitions, although not more than twelve to twenty times in one go (or set). Whether you are looking for larger muscles or good muscle tone, you would never repeat each set of repetitions more than two or three times. Because your muscles need time to heal and become stronger after these sessions, you should never do strength training with the same body parts two days in a row. Cardio and strength activities have been shown to have equal benefts to physical and mental health. As is the case with cardio activities, the greatest benefts have been found in people who engage in this form of exercise four days a week, at moderate to high intensity. Flexibility Training Flexibility training includes activities where the muscles are being gently stretched. Stretching and increasing fexibility can be an important part of preventing injury. Once you get in the habit of stretching, you will look forward to the pleasure of releasing those muscles. Instead, you should gradually stretch the muscle until you feel mild tension but not pain, and hold your stretch for a minimum of twenty to thirty seconds, and a maximum of sixty seconds; this type of stretching is called static stretching. A number of physical activities have stretching built into them, such as dancing, curling, yoga, bowling, golfng, and garden 84 Changing Your Lifestyle: Designing Your Activity Plan ing; these involve dynamic stretching. You may need help learning how to stretch your muscles, and a personal trainer, videos, or books can be very useful in teaching you the proper technique. If you are going to experience benefts to your physical and mental health, the intensity of your activity will need to fall within a recommended range. Step 1 Take your pulse for sixty seconds in the morning after waking up naturally (the sound of an alarm clock causes your body to release adrenaline and speed up your heart rate) or after a period of rest, when you feel relaxed and haven?t consumed any caffeine or stimulants. To take your pulse, try placing your fnger on the side of your neck or below your thumb on your wrist. Enter the numbers and perform the numerical operations one after the other to arrive at your minimum working heart rate. If your heart rate rises closer to the maximum, you are working at a high intensity, which would be appro priate for shorter sessions. If you can manage two or three-word phrases, you are likely working in the moderate to high-intensity range. If you can?t manage even two or three-word phrases, your level of intensity is too high. Your Cardio Level Answer the questions below to determine your cardio activity level. When you engage in cardio activity, how long do you typically exercise in each session? What changes would you need to make in order to bring your cardio activity into healthy guidelines (20-60 minutes, 3-6 times per week)? Over a typical seven-day period, how many times do you engage in muscular work requiring pushing, pulling, lifting, and the like? Less than 8 Your weights are too heavy, or the repetitions activity you are choosing is too hard. What changes would you need to make for your strength training activity to fall within healthy guidelines (2-3 set of 12-20 repetitions, 3 to 4 times per week)? What changes would you need to make for your fexibility level to fall within healthy guidelines (3-6 times per week holding each stretch for 30-60 seconds)? Now that you have assessed your ftness level, you can identify areas for improvement. We will help you plan for change, but frst you can summarize what you need to do to bring yourself within the healthy physical activity guidelines described above. If your physical activity is in line with your life priorities, you are more likely to continue with the activity. Next, complete the second column to highlight the 3-5 priorities that are most important to you. For example, you may feel strongly that you want to spend more time with your family but not care about whether you are doing something familiar or trying something new. Your Preferences Your Current Life Priorities (In each box, select one preference. Matching Your Priorities to Specifc Physical Activities Consider the physical activities listed below and decide whether any of them would satisfy the priori ties or preferences you identifed above. The frst column lists activities that require you to set time aside and are often (although not always) done independently. The second column lists activities that require you to belong to a team or play with a partner. The third column lists daily-living activities for people who want to build activity into their lifestyle and like to feel productive when they are active. Tai chi Write down the physical activities you selected that you know you could take part in immediately: Write down the physical activities you selected that you would need to research or prepare for before you could start: Take one week to look into the activities that interest you and then move toward designing your plan, as described below. Fill in your plan below: Cardio Activity Time (Duration) Activity An example: Weekday: 2 x 10 min. Total for Day Your plan: 93 the Cognitive Behavioral Workbook for Weight Management Strength Training Days per Week Activity An example: 2 days (Wed. However, even with a good plan, you might never get started if you fnd ways to put it off. For some people, one effective form of commitment is to spend some money: buy yourself the equipment or clothing you will need for your chosen activity, pay to enroll in a class, or hire a personal trainer. Another way of making a commitment is to involve other people in your plans: fnd a friend who wants to start being active, choose an activity where people need you to be there (such as a sports team or doubles tennis), or join a group of people who are already active (such as a walking group). Finally, make a commitment of your time: set the date on which you will get started, and add the workout to your schedule and your calendar. Below, write the ways you will increase your commitment: Before You Get Started: Some Final Words Incorporating physical activity in your life is a crucial step toward improving your overall physical and psychological well-being. She decided to join a local walking group led by a dynamic woman committed to the benefts of power walking. Janice felt she could quite easily keep up this activity while traveling, since most of the hotels she stayed in had treadmills that were available to guests. Your Daily Plan Sheet In chapter 5, you began to use a Daily Plan sheet to plan and track your eating. We have provided a similar sheet for you to use in planning and tracking your activity. Use both sheets on a daily basis until you feel that your eating and activity have settled into a healthy routine. You will use this information when you work through the chapters on overcoming obstacles. This chapter will focus on some of the most common obstacles: the situational triggers. Self-monitoring involves tracking your own experiences so that you learn exactly what factors put you at risk. Once you know what your triggers are, you can use various strategies to reduce your risk of reacting to those triggers. In chapter 5, you wrote out your daily plan for eating and tracked what you actually ate. In this chapter, you are tracking the times when you don?t follow your eating or activity plan for the day. For example, maybe you had a bad day and ate way more for dinner than you had planned. Maybe you skipped breakfast or canceled on your friend who was meeting you for your daily walk. These kinds of events are your cue to begin looking for the trigger that derailed your efforts. Once you know you are off track, you will follow the seven steps for self-monitoring, described below. Dealing with Bumps in the Road Jim was talking with his doctor about weight-loss surgery and trying to follow the balanced defcit weight-loss plan in order to get used to more regular and balanced eating. He made his plan (three thousand calories, as calculated using the formulas in chapter 5) but ran into his frst problem fairly quickly. On these days, he found himself falling back into old habits: forgoing physical activity and turning to fast food for dinner. If you review your day and see many misses, you may want to work on only one or two things at a time. So, if all your meals and snacks didn?t match what you planned, then you might start with the meal that came closest or that you think would be the easiest to fx. This meal is now your problem, and you will think only of this as you fll in the rest of the steps. Jim identifed his problem as follows: I didn?t eat the dinner I had planned, and I didn?t do the exercise I had scheduled for this afternoon. Jim described the situation by saying, I was home alone with the kids because my wife is working nights this week. I was rushing around getting the girls to their soccer game and I had to pick up dog food because we were out, so I grabbed some fast food for dinner instead of cooking a healthy meal. Chapter 8 will give you a complete list of possible emotions if you need help identifying what you feel. Note them all and rate each of them in 99 the Cognitive Behavioral Workbook for Weight Management intensity from 0 (not at all intense) to 100 (extremely intense). When you begin to work on emotional triggers, focus on the emotion that you rate the most intense. Jim described his emotions by saying I felt overwhelmed, stressed, and helpless, and he identifed his feeling of being overwhelmed as the strongest emotion, with an intensity of 80 out of 100. To get at the thoughts that will be the most useful, focus on the emotion you identifed in step 3 as the most intense. Try to complete the fol lowing sentence: I was feeling [fll in the emotion that was most intense] because [fll in the possible reason you felt that emotion]. Jim described his thoughts by saying, I was feeling overwhelmed because I couldn?t cope with all the demands on my own. I?m never going to be able to do things for myself; my needs just don?t take priority. In this step, you consider whether any personal interactions were related to the problem you identi fed. Consider whether any interactions occurred at the time of the problem, or if any past interactions might have put you at risk. This morning, when we talked about the plans for the day, she was exasperated when I mentioned my plans, and she said, Jim, you know the girls have soccer. I put the kids schedule frst and dropped my plans for eating and physical activity. Jim reviewed the different situational, emotional, and interpersonal information he had collected, and determined that it was mostly the situation that had put him at risk. Take a look at the Daily Eating, Activity, and Self-Monitoring Worksheet that follows. Situation: Home alone, rushing the girls to their soccer game and had to pick up dog food 3. What I thought: I felt overwhelmed because I can?t cope with all these demands on my own. To be successful, you must make time in your schedule each day to fll in your self-monitoring sheet. Ideally, you should record your eating throughout the day, right after you eat, especially because research suggests that our recall of food intake is not very reliable (Mulheim et al. At the least, make time each evening to record your eating as accurately as you can remember. Complete the bottom of the sheet whenever you check off the columns that indicate you ate less or more than you planned. You should also record when you have urges to get off track but manage to stay on track anyway. This will help you fgure out what triggers make you vulnerable to slipping back into your old habits. Use the complete Daily Eating, Activity, and Self-Monitoring Worksheet (including the food you plan to eat) for your frst month or two of following your new plan. In this chapter and the two that follow, you will learn strategies for dealing with the situations, emotions, and interactions you identify as putting you and your plan at risk. The strategies you will learn will require you to actively pay attention to the triggers that make you vulnerable and then deal with them head-on. In the fnal step of your self-monitoring process, you are asked to consider what you have learned. It is at this point that you decide which type of trigger caused you to depart from your plan: situational, emotional, or interpersonal. Once you identify the trigger you believe is responsible for pushing you off track, you need to decide whether you think this trigger is likely to be a problem again for you in the future. If you think you will run into this trigger again, then you will need to actively plan ahead for the next time. Situational Triggers: Problem Solving and Planning Ahead the solution for practical, everyday, situational problems relies entirely on common sense. You are simply going to apply yourself to the problem and see if you can come up with solutions that work; in other words, you will do some problem solving. We will take you through the problem-solving and planning-ahead process below and make suggestions 104 Dealing with Bumps in the Road that we hope will improve your chances of fnding a successful solution. Jim identifed his busy schedule on the days his wife worked as the trigger for falling off his plan. Now that he had identifed this situational trigger, Jim was motivated to fnd a better way of managing this situation. Now that he had broken it down to a problem he could solve, it seemed more possible for him to stay on track with his eating and activity plan. Build physical activity into my day on these busy days; if I am at the soccer park, walk up and down the side of the feld while the girls are at practice. Then go through each possible solution individually and consider the following: What are the pros and cons? In reviewing each of his possible solutions, Jim realized that they really couldn?t afford the options that required extra money, like hiring someone to help out or paying for a meal service. He didn?t think it was a good idea to rely on fast-food restaurants, as he was afraid he?d make a bad choice and was reluctant to spend money to eat out. In the end, he thought the best option would be to plan his meals ahead of time and freeze them so he could pull them out and heat them up quickly when things were hectic. With respect to physical activity, Jim was worried that if he tried to build physical activity into his day, he wouldn?t do very much at all?and he liked to chat with the other parents at the park. He also didn?t like the carpool idea because then he would be obligated to reciprocate and that might add more pressure. He thought the idea of getting up early to ride his exercise bike seemed like the best option. Each of these items would be enough to feed the family for two dinners; once when he made them and a second time after freezing them. He planned to buy precut vegetables that could easily be taken out of the fridge for a quick snack or to accompany the meal.
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