Joshua Augustine, MD

• Associate Professor of Medicine
• Cleveland Clinic Lerner College of Medicine Cleveland Clinic Cleveland, Ohio

The fetus is also exposed to local prolactin prostate lymph nodes cheap 5 mg fincar visa, via the amniotic fluid man health nursing environment 5mg fincar visa, which fills the lungs and is also swallowed man health policy 5 mg fincar amex, with possible benefits (see ?Newborn and Later Prolactin mens health 28 day muscle order on line fincar, below) prostate cancer metastasized buy fincar without prescription. Maternal Prolactin after Birth the function of physiologic prolactin elevations in the hours after birth is not known prostate ultrasound cpt order genuine fincar line, but may be impor tant in promoting prolactin receptor formation, breast-milk production, and maternal adaptations. In animals, early maternal postpartum elevations of the stress hormone corticosterone (equivalent to human cortisol, 6. Prolactin levels are elevated in the newborn,106 peaking from 30 to 60 minutes after birth, then declin ing. Maternal prolactin release with lactation, and prolactin content in breast milk, is maximal in early lactation. Stress may disrupt lactation by reducing prolactin release, possibly via epinephrine-norepi nephrine elevation and/or suppression of pulsatile oxytocin. Early postpartum prolactin elevation from early and frequent suckling, may be critical for establishing prolactin receptors and an abundant ongoing milk supply (?prolactin receptor theory). Prolactin is also involved with non-maternal infant caregiving in many species, including in human fathers. However, many common maternity care interventions can potentially impact this important system, with significant long term detriments in mothers and babies if breastfeeding is unsuccessful or foreshortened. The success of breastfeeding may have long-term impacts on the prolactin systems of both mother and baby. Prostaglandin-exposed newborn piglets had lower white cell numbers,1120 suggesting further effects on offspring immunity. Ergot drugs, used alone or with synthetic oxytocin to prevent hemorrhage after birth, are known to inhibit prolactin release and some studies suggest impacts on breastfeeding success. With induction by any method, both mother and baby are likely to miss the full prelabor physiologic preparations. Impaired or foreshortened breastfeeding may have significant and possibly long-term effects on prolactin systems in mothers and babies (see 6. Lower postpartum prolactin levels, as suggested in two studies, could impact developing prolactin sys tems and breastfeeding, but this has not been specifically studied. Epidurals may have effects on breast feeding success, discussed elsewhere, with significant longer-term impacts on maternal and offspring prolactin systems. Unsuccessful breastfeeding may have significant and possibly long-term detrimental effects on prolactin sys tems in mothers and babies. Researchers have found reduced breastfeeding-related prolactin release following in-labor unplanned cesarean compared with vaginal birth. Lower fetal/newborn prolactin along with deficits in prelabor preparations, could im pact newborn breathing and temperature transitions. All these factors may contribute to reduced breast feeding success following prelabor cesarean. One study measured new mothers hormonal release during breastfeeding on day two in relation to mode of birth. Maternal prolactin elevations from early pregnancy have stress-reducing effects that also benefit the fetus. Late-pregnancy prolactin elevations promote the formation of prolactin receptors in the brain and mam mary gland (animal studies). Fetal prolactic production increases close to the physiologic onset of labor, and may promote newborn transitions. Maternal prolactin paradoxically declines as labor advances (outside of labor, stress triggers prolactin re lease). Prolactin increases steeply as birth nears, likely due to peaks of beta-endorphins and oxytocin, both of which stimulate prolactin release. In addition, prolactin stimulates oxytocin release, contributing to oxytocin peaks in late labor and birth. Prolactin levels released during early breastfeeding have been correlated with mater nal adaptations, including: reduced anxiety, aggression, and muscular tension; and increased social desir ability (conformity), which may help mothers to prioritize infant care. Stress in labor may paradoxically reduce prolactin secretion, giving infraphysiologic levels in labor and birth, possibly contributing to the negative impacts of labor stress on breastfeeding. Epidurals may cause in-labor prolactin elevations and postpartum prolactin reductions, with unknown impacts. With cesarean section, the expectant mother may miss her pre-labor prolactin elevation, late-labor peak and/or postpartum elevations, which may all impact milk production and maternal adaptations. Follow ing cesarean section, prolactin release with early breastfeeding may be reduced or absent. Fol lowing cesarean section, newborns may have lower prolactin levels, possibly contributing to breathing difficulties and low temperature. If separation interferes with early breastfeeding initiation and frequency, disruption to prolactin receptor formation may impact ongoing milk production and breastfeeding success. The recommendations that follow give guidance for educators, clinicians, researchers, policy makers, advocates, and childbearing families for safely optimizing the hormonal physiology of childbearing. While beneficial in selected circumstances, maternity care interventions may disrupt these beneficial processes. Because of the possibility of enduring effects, includ ing via epigenetics, the Precautionary Principle suggests caution in deviating from these healthy physi ologic processes in childbearing. This report documents in detail the hormonal physiology of childbearing, including:? This evidence also suggests that the benefits of physiologic childbearing for mothers and babies may ex tend into the future through successful breastfeeding and optimizing of mother-baby attachment, with substantial benefits for modern mothers and babies, as they have had for our evolutionary ancestors. Maternity care interventions are beneficial and even lifesaving in selected circumstances. This report provides considerable evidence that they can also cause significant disruptions to hormonal processes in mother and baby with unintended consequences, as summarized in Table 4. The hormonal physiology perspective provides additional information, germane to the well-being of women and offspring, for clinicians, women, and others to consider when weighing benefits and harms of mater nity care practices and interventions, both for care of individual mothers and babies and at a policy level. Biologic principles and solid findings from animal studies suggest that hormonal system functioning in the perinatal period, whether optimal or disrupted, may have enduring impacts on offspring hormonal and other biologic systems. This may occur via epigenetic programing, with possible longer-term effects on development, behavior, and/or hormone system functioning, as seen in animal studies. The known unintended shorter-term hormonal and other impacts of perinatal interventions, and evolving evidence about their possible longer-term effects invoke a strong case for the Precautionary Principle. First, for all of the hormone systems examined in this report, greater elucida tion is needed of the underlying innate hormonal physiology as it relates to the processes of childbear ing, with a priority for research in humans whenever possible. Second, better understanding is needed of possible impacts of widely used maternity care interventions. A particularly urgent research priority is longer-term follow up to assess whether interventions?includ ing elective induction; administration of synthetic oxytocin, before, during and/or after labor and birth; epidural analgesia; and prelabor cesarean?impact crucial hormonally-mediated outcomes in women and babies, such as breastfeeding, maternal adaptations, maternal-infant attachment, maternal mood states, and offspring hormonal functioning. Such impacts are plausible given the principles and processes de scribed in this report, but poorly researched. Urgent as well are questions about whether perinatal inter ventions have enduring developmental, and possibly epigenetic, effects in humans, as found in animals. All who are involved in maternity care are committed the best possible care, with the least harm, to mothers and babies. The research results synthesized here, along with underlying hormonal physiology principles and understandings, clarify that promoting, supporting and protecting physiologic birth is a simple, low-technol ogy approach to health and wellness that is applicable in the vast majority of maternity care settings. The perspective of hormonal physiology provides a new framework with which to view childbearing, and can contribute to a salutogenic foundation for the care of mothers and babies. This perspective can pro vide direction for promoting, supporting, and protecting:? The only thing required of the bystanders under these conditions is that they show respect for this awe inspiring process by complying with the first rule of medicine, that of nil nocere [do no harm]. Benefits of hormonal physiology accrue, so that any safe enhancement of hormonal physiol ogy will likely benefit women and babies to some degree. Greater conformity with physiologic processes is likely to be more beneficial than less conformity. Additional benefits are also likely from averting potential harms associated with unneeded interventions. The synthesis presented in this report supports a series of recommendations for safely optimizing hormonal physiology within maternity care. Currently available research, as presented in this report, consistently finds that physiologic childbearing confers valuable benefits to women and their babies in the short, medium, and likely longer terms. The benefits that accrue from optimizing hormonal physiology for mother and baby extend along a contin uum, according to this framework, with greater benefits likely for any mother and baby with greater ex perience of physiologic processes. Additional benefits from averting unneeded maternity care practices that have potential to harm women and babies, both known harms and any that are currently unknown, also likely extend along a continuum. Maternity care systems could be readily adapted to safely optimize hormonal physiology for mothers and babies. They do not exclude the timely, appropriate, and safe use of maternity care procedures, medications, and other interventions when needed for the well-being of women and babies, in which case the recommendations can help maximize hormonal physiology as far as possible, and safely move women and babies along the salutogenic continuum. The Appendix identifies selected resources that support implementation of these recommendations for professionals, and for women and childbearing families. This will foster provision of high-qual ity care, effective care teams, and more judicious use of maternity care interventions. This will enable a more complete and accurate assessment of possible benefits and harms. It is important for health professionals to be able to provide physiologic care to the extent safely possible for women and babies with special conditions, needs, and care requirements. This knowledge and associated skills, along with a meaningful practical experience of physiologic child bearing, should be a foundational component of all levels of professional education within all of the dis ciplines that care for childbearing women and newborns. These subjects should be introduced in entry level education, well represented during more advanced professional training, and prioritized within continuing education, including maintenance of certification programs. Policy Use effective quality improvement strategies to foster reliable access to physiologic childbearing. These include: addressing physiologic childbearing within quality collaboratives, developing relevant perfor mance measures and using them for quality improvement, developing and implementing protocols that promote physiologic childbearing, using innovative payment and delivery systems to foster appropriate care practices, and implementing evidence-based clinical practice guidelines including those to safely reduce use of cesarean section and other consequential interventions. Strengthen and increase access to care models that foster physiologic childbearing and safely limit use of maternity care interventions. These and other models and maternity care providers that prioritize and support physiologic processes should be encouraged. Facilities, maternity care providers and/or models of care with good safety outcomes and low rates of maternity care interventions likely are skilled in promoting, supporting, and protecting physiologic birth. Professional development can help maternity care facilities and practitioners with limited ability to facili tate physiologic childbearing obtain the needed knowledge and skills to provide optimal care for healthy childbearing women and newborns. Maternity care providers with skills and expertise in the care of women and babies with higher-risk and/or specific conditions provide critical maternity care services. For example, women with challenging conditions would likely benefit from one-on-one care in labor and skin-to-skin contact after birth. Similarly, breastfeeding in the early sensitive postpartum period following cesarean section is a priority. Models of care and protocols that safely apply these principles to women at higher-risk should be developed. Engaging and supporting childbearing women Use effective consumer engagement strategies to inform women about physiologic childbearing and involve them in related aspects of their care. This booklet, and related resources that can help women understand the hormonal physiology of childbearing, should be widely distributed and recommended to pregnant women and women planning pregnancy. Childbearing women should also have access to publicly reported results of performance measures that provide relevant information for choosing a care provider or group and a birth setting. Priority decision aids for childbearing decisions of great consequence should include relevant information and be routinely incorporated into maternity care prac tice. All women should have access to care that safely supports physiologic childbearing and to care environments that promote such care and protect women from the harm of unneeded disturbance of physiologic processes, as described in this report. Where childbearing deviates from optimal hormonal physiology, or extra assis tance or interventions are required, women should be fully supported to maximize hormonal physiology. Journalists have a role to play in informing childbearing women and the general public about these matters. Some aspects of prenatal care, including fetal testing, may contribute to , or fail to reduce, maternal stress and anxiety. Evolving evidence suggests that some forms of relax ation and relaxation training may improve not only physiologic and hormone stress markers but also meaningful outcomes in mothers and babies. Current evidence suggests that effective relaxation techniques that reduce stress may favorably influence maternal emo tional states, stress hormones, and responses; and fetal growth and behavior, premature birth rate, mode of birth, and newborn neurobehavior, among other impacts. Scheduled birth, whether by induction or prelabor cesarean, will foreshorten these processes in mothers and babies, with potentially significant consequences for their physiologic transitions. With a prelabor cesarean, mothers and babies also miss beneficial processes of labor that activate maternal and fetal hormonal systems to optimize postpartum transitions of both. From the perspective of hormonal physi ology, when a scheduled cesarean is needed, waiting when possible for labor to start on its own may offer benefits to mothers and babies. Due to many currently unanswered questions about possible hormonally-mediated effects of scheduled birth, policies that support the physi ologic onset of labor at term and discourage unneeded induction of labor or prelabor cesarean in healthy mothers and babies are prudent. Disturbance in labor?including being in an environment that is not perceived as familiar, private, or safe?may slow or stop labor by increasing stress and stress hormone levels. In women who plan hospital birth, moving from the familiar environment of home to the unfamiliar environment of hospital may slow labor, especially before the positive feed back cycles that progress labor are fully established, making labor less vulnerable to disturbance. Waiting for active labor be fore moving from home to hospital may reduce the risk of physiologic disruptions and is associated with increased likelihood of vaginal birth. Providing telephone support and/or a caregiver who is available to attend and assess the laboring woman at home, if needed, could be a cost-effective way to enhance physiologic processes, especially in first-time mothers. Establishing a trusting relationship with caregivers is also likely to be beneficial. Make non-pharmacologic comfort measures for pain relief routinely available, and use analgesic medications sparingly.

The Comments section includes other explanatory caregiver/teacher prostate cancer in women buy fincar with a visa, with one or more qualifed adult information relevant to the standard prostate cancer screening buy fincar with visa, such as applicability of assistants to meet child: staff ratio requirements mens health xtreme nitro buy generic fincar 5mg on line. Although this document of any number of children in a nonresidential setting mens health pdf discount fincar 5 mg free shipping, refects the best information available at the time of publica or thirteen or more children in any setting if the facility is tion mens health xtreme buy fincar no prescription, as was the case with the frst and second editions prostate oncology 47130 buy discount fincar line, this open on a regular basis. Many of these legal requirements have a different intent from that addressed by the standards. Users of this document should check legal requirements that may apply to facilities in particular locales. A number of different codes are intended to prevent the spread of disease in restaurants, hospitals, and other institutions where hazards and risky practices might exist. Many of these health codes are not specifc to child care; however, specifc provisions for child care might be found in a health code. Usually, before a child care operator receives a license, the operator must obtain approvals from health and building safety authorities. In an effective regulatory system, differ ent inspectors do not try to regulate the same thing. Recommends healthy full-term infants can be safely language on what a care plan should cover for the rare ex enrolled in child care settings beginning at three months of ception of a child with a special behavioral or mental health age. Moved chart to Appendix K and updated defni ing throughout the infant-related standards. Updated with more specifcity to content of milk, and avoiding concentrated sweets and limit types of animals allowed and under what conditions. Updated with more breastfed infant feeding patterns in collaboration with fami specifcity on caring for animals in child care settings. Adds information about previous treatment be prepared and gives example in new Appendix O. Discusses allowing soy products with par dated information on those conditions for which staff should ent/guardian request. Increases emphasis on age-appropriate portion size and eating from developmentally appropriate tableware Standard 5. Emphasizes using teachable moments throughout terials with the least probability of containing materials that year and importance of good nutrition and appropriate off-gas toxic elements. Cribs with drop sides not per minimum space per child from thirty-fve to forty-two square mitted. Adds candles as items to be inaccessible to stoves should be inaccessible to children and should be children. Prohibits trampo care once symptoms have resolved and temperature has lines in child care programs both onsite and during feld returned to normal. Updated to include requirements of riding toys risk of acquiring new infection or state/local health depart and wheeled equipment including scooters and all riders ment requires. Updated on mends children with enterovirus infections should not be current requirements for car safety seats, booster seats, excluded unless meet certain criteria. Recommends all children have age appropriate immuniza Standards on immunizations moved from Chapter 3 to tions, and those not immunized or not age appropriately Chapter 7. Recommends not exclud documentation that a child six months of age and older has ing children and staff unless meet certain criteria. Lesions current annual vaccination against infuenza unless there should be covered. Adds to list of policies needed: Menu and meal increases of small family child care home fees. Expands types of consultants by adding early childhood education consultant, Standard 9. Recommends contents of a plan in the areas of planning and coordination, infection control Standard 10. Includes signs and symptoms of illness, whether to notify a child care health consultant, whether to notify parent/guardian, whether to exclude child and if excluded, when to readmit. Care must be taken so the small family child care home caregiver/teacher that placement of cribs in an area used by other children child:staff ratios should conform to the following table: does not encroach upon the minimum usable foor space requirements. Infants do not require a dark and quiet place If the small family child then the small family child for sleep. Once they become accustomed, infants are able care home caregiver/ care home caregiver/ to sleep without problems in environments with light and teacher has no children teacher may have one noise. By placing infants (as well as all children in care) on under two years of age to six children over two the main (ground) level of the home for sleep and remaining in care, years of age in care on the same level as the children, the caregiver/teacher is If the small family child then the small family child more likely able to evacuate the children in less time; thus, care home caregiver/ care home caregiver/ increasing the odds of a successful evacuation in the event teacher has one child teacher may have one to of a fre or another emergency. Caregivers/teachers must under two years of age three children over two also continually monitor other children in this area so they in care, years of age in care are not climbing on or into the cribs. These behaviors may ily requiring supervision should be included in the child:staff go undetected if a caregiver/teacher is not present. During nap time, at least one adult should be physi giver/teacher is not able to remain in the same room as the cally present in the same room as the children. Infant and Each state has its own set of regulations that specify child development and caregiving quality improves when child:staff ratios. The recommended group size and child:staff of school-age children that are allowed to be cared for in ratio allow three to fve-year-old children to have continuing small family child care homes. Since school-age children require focused homes serve no more than two clients incapable of self caregiver/teacher time and attention for supervision and preservation (5). The family child care Direct, warm social interaction between adults and children caregiver/teacher must be able to have a positive relation is more common and more likely with lower child:staff ratios. This Caregivers/teachers must be recognized as performing a standard is consistent with ratio requirements for toddlers in job for groups of children that parents/guardians of twins, centers as described in Standard 1. In child care, these children do not come from the same Unscheduled inspections encourage compliance with this family and must learn a set of common rules that may differ standard. Care and Development Block Grant: Improving quality child care for infants and toddlers. Supporting growth 13-35 months 4:1 8 and development of babies in child care: What does the research say? Effects of child-caregiver ratio on the interactions between 6 to 8-year 10:1 20 caregivers and children in child-care centers: An experimental olds study. Department of Health and Human older, at least one adult should be physically present in the Services, Offce of the Assistant Secretary for Planning and same room as the children and maximum group size must Evaluation. New York: Cambridge University usually be organized to nap on a schedule, but infants and Press. In the event even one child is not sleeping the healthy development and school readiness of infants and toddlers. The caregiver/teacher who is Child Care Homes and Centers in the same room with the children should be able to sum Child:staff ratios in large family child care homes and mon these adults without leaving the children. When infants or toddlers are in the mixed age group, the child:staff ratio and group size for Age Maximum Maximum infants and toddlers should be maintained. In large fam Child:Staff Group Size ily child care homes with two or more caregivers/teachers Ratio caring for no more than twelve children, no more than three children younger than two years of age should be in care. The standard for child:staff ratios in this Chapter 1: Staffng 4 Caring for Our Children: National Health and Safety Performance Standards document uses a single desired ratio, rather than a range, closer observation and the frequent need to interact with for each age group. Close stringent ratios to support quality experiences for young proximity of staff to these younger groups enables more children. Group size and in an area next to the nap room so other staff can assist if ratio of children to adults are limited to allow for one to one emergency evacuation becomes necessary. If a child with a interaction, intimate knowledge of individual children, and potentially life-threatening special health care need is pres consistent caregiving (7). Caregivers/teachers must be recognized as performing a Group size is the number of children assigned to a care job for groups of children that parents/guardians of twins, giver/teacher or team of caregivers/teachers occupying an triplets, or quadruplets would rarely be left to handle alone. Child:staff ratios in child care settings should be Community resources, in addition to parent/guardian fees suffciently low to keep staff stress below levels that might and a greater public investment in child care, can make criti result in anger with children. Caring for too many young chil cal contributions to the achievement of the child:staff ratios dren, in particular, increases the possibility of stress to the and group sizes specifed in this standard. Each state has its caregiver/teacher, and may result in loss of the caregiver?s/ own set of regulations that specify child:staff ratios. The Care and Development Block Grant: Improving quality child care for facility may wish to increase the number of staff members if infants and toddlers. Supporting growth Family Child Care Home and development of babies in child care: What does the research say? Early childhood program standards and Child:staff ratios established for out-of-home child care accreditation criteria. Child care and the well-being around a vehicle, when children are in a car, or when they of children. Health in child be conducted prior to leaving for a destination, when the care: A manual for health professionals. Department of Health and Human Services, Offce of the Assistant Secretary for Planning and when they are being transported, in loading zones, and Evaluation. Fatalities and the organization of to focus entirely on driving tasks, leaving the supervision child care in the United States. Serving Children with Special Health Care In any vehicle making multiple stops to pick up or drop off children, this also permits one adult to get one child out and Needs and Disabilities take that child to a home, while the other adult supervises Facilities enrolling children with special health care needs the children remaining in the vehicle, who would otherwise and disabilities should determine, by an individual assess be unattended for that time (1). Moving kids safely in child care: A refresher encourage each child to participate comfortably in program course. Proper Swimming, Wading, and Water Play ratios during swimming activities with infants are important. Infant swimming programs have led to water intoxication the following child:staff ratios should apply while children and seizures because infants may swallow excessive water are swimming, wading, or engaged in water play: when they are engaged in any submersion activities (1). Consumer who is supervising children of any age should be focused Product Safety Commission. American Academy of Pediatrics, Committee on Injury, Violence, close continuous supervision (1,4), four-sided fencing and and Poison Prevention, J. Technical report: Prevention self-locking gates around all swimming pools, hot tubs, of drowning. Drowning is a ?silent killer and Healthy full-term infants can be enrolled in child care set children may slip into the water silently without any splash tings as early as three months of age. This ratio excludes cooks, maintenance workers, or dergo rapid development over the frst ten to twelve weeks lifeguards from being counted in the child:staff ratio if they of life (1-6). Concurrently, and as a direct consequence of 7 Chapter 1: Staffng Caring for Our Children: National Health and Safety Performance Standards these shifts in central nervous system structure and func fourteen versus twenty-four weeks as compared to the U. On-the-job moms: Work and breastfeeding initiation and duration for a sample of low-income women. Maternal Birth of a child or adoption of a newborn, especially the Child Health J 10:19-26. Chapter 1: Staffng 8 Caring for Our Children: National Health and Safety Performance Standards 9. Parental leave policies Reasons to deny employment include the following: in 21 countries: Assessing generosity and gender equality. Maternity leave in the b) Accommodation is unreasonable or will result in United States: Paid parental leave is still not standard, even among undue hardship to the program; the best U. In addition, child care businesses should model diver for quality: the critical importance of developing and supporting a skilled, ethnically and linguistically diverse early childhood sity and non-discrimination in their employment practices to workforce. Department of Justice, Civil Rights Division, Disability Rights and tolerance for individuals on the staff who are competent Section. Commonly asked questions about child care centers caregivers/teachers with different background and orienta and the Americans with Disabilities Act. Discrimination child abuse or neglect to another person, the obvious at based on sexual orientation, status as a parent, marital status and tention directed to the question by the licensing agency or political affliation. Having a small family child care homes should conduct a complete state credentialing system can reduce the time required to background screening before employing any staff member ensure all those caring for children have had the required (including substitutes, cooks, clerical staff, transportation background screening review. The background and caregivers/teachers who are asked to submit a back screening should include: ground screening record should contact their state child a) Name and address verifcation; care licensing agency for the appropriate documentation b) Social Security number verifcation; required. Fingerprinting can be secured at local law enforce c) Education verifcation; ment offces or the State Bureau of Investigation. Court d) Employment history; records are public information and can be obtained from e) Alias search; county court offces and some states have statewide online f) Driving history through state Department of Motor court records. When checking for prior arrests or previous Vehicles records; court actions, the facility should check for misdemeanors g) Background screening of: as well as felonies. Driving records are available from the 1) State and national criminal history records; State Department of Motor Vehicles. A social security trace 2) Child abuse and neglect registries; is a report, derived from credit bureau records that will 3) Licensing history with any other state agencies return all current and reported addresses for the last seven. If there are alternate names (aliases) 4) Fingerprints; and these are also reported. State child abuse registries can be 5) Sex offender registries; accessed at. Sex offender registries can be accessed at All family members over age ten living in large and small. Companies also offer family child care homes should also have background background check services. Written permission to obtain the background For more information on state licensing requirements re screening (with or without a drug screen) should be ob garding criminal background screenings, see the National tained from the prospective employee. Although few persons will acknowledge past level course work in administration, leadership, or Chapter 1: Staffng 10 Caring for Our Children: National Health and Safety Performance Standards management, and at least twenty-four credit-bearing making that affects their day-to-day practice (5,6). Manage hours of specialized college-level course work in ment skills are important and should be viewed primarily as early childhood education, child development, a means of support for the key role of educational leader elementary education, or early childhood special ship that a director provides (6). Past experience working in an early b) A valid certifcate of successful completion of childhood setting is essential to running a facility. The exact com g) Oral and written communication skills; bination of college coursework and supervised experience is h) Certifcate of satisfactory completion of instruction in still being developed. Cost, quality and child outcomes in child effect on quality child care, whereas experience per se has care centers. Standards for early childhood professional the director of a center plays a pivotal role in ensuring the preparation programs.

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The increase in ve tion to pressure generation prostate cancer quality of life purchase fincar 5mg with amex, and that the rectus abdo nous pressure may result in rupture of subconjunctival androgen hormone definition cheap fincar online visa, minis muscle minimally contributes to pressure nasal and anal veins mens health low testosterone symptoms buy discount fincar 5mg on line. Cough has thus been used abdominal muscle activity prostate 24 reviews fincar 5 mg low price, particularly the obliquus as a form of cardiopulmonary resuscitation to restore externus muscle prostate questionnaire purchase fincar 5mg on-line, have been used to assess the intensity a more normal cardiac rhythm in patients with poten of coughs elicited by inhalation of tussigenic agents tially lethal arrhythmia [18] prostate cancer options for treatment purchase 5mg fincar otc. Am J Med Sci of the obliquus externus muscle has been used to evalu 1937; 194: 523?35. Me In dogs, both the triangularis sternii and the trans chanics of Breathing, Sect. In tetraplegic sub ical parameter of cough: the larynx in a normal single jects, contraction of the clavicular portion of the cough. Am J Respir Crit of subjects with normally movable cords and patients with Care Med 1999; 160: 1578?84. J Appl Role of costal and crural diaphragm and parasternal Physiol 1974; 36: 653?67. Respiratory effects of the external and internal intercostal Chest 1998; 114: 113s?81s. J Appl Physiol terolateral abdominal muscles during cough and expirat 1983; 55: 1?8. J Appl Physiol 1994; 77: Mechanical contribution of expiratory muscles to pres 1577?83. An electromyographic Role of triangularis sterni during coughing and sneezing in method of objectively assessing cough intensity and use of dogs. Cough in tetraplegic subjects: an non-invasive electromyographic study on threshold and active process. Michael Foster Introduction health and a physical adjunct to mucociliary clearance in hypersecretory airway disease [8,9]. The tracheobronchial airways of the human lung are largely covered by a liquid lining of mucus. The mucus is a viscoelastic secretion that serves as a barrier for en Sources of airway mucus trapment of microorganisms and xenobiotic material and protects the underlying mucosal tissues from dehy In humans cellular sources of the mucin component of dration. Current understanding is that the liquid lining is within all airways and extend to the level of the alveolar a two-phase model in which the super? Submucosal coelastic (mucins, tangled network of high molecular glands, due to their prominence in airway histological weight polymers) gel phase that overlays a periciliary section, are considered to secrete the major contribu sol phase (serous). This calculation was based on several assump to be propelled by ciliary beating and? Recent in vitro studies suggest that contributions of goblet cells and glands to the mucin perhaps the periciliary layer is not stationary but may component of airway mucus are uncertain and likely to move unidirectionally via ciliary activity [5]. The normal ity of mucus layer transport can be fairly rapid in the daily output of tracheobronchial secretions does not tracheal airway, i. Mucociliary transport and re Control of mucus secretion placement of the mucus layer is in? Mechanisms that regulate the quality and volume interaction with mucus-producing cells. This concept of the respiratory secretions involve, for example, the is supported by explants of human tracheal tissue in transepithelial secretion of the chloride ion across which integrin binding of neutrophils was required to the airway epithelium with passive diffusion of water, induce degranulation of mucus cells [17]. A uniform the stimulation of secretion by a number of mediators airway response following exposure to respirable such as arachidonic acid metabolites, and the overall irritants. In addition to airway mucus produced by goblet cells and submucosal stimulation of neural re? Changes in the composition of secreted glycopro the major determinants for viscoelastic and adhe teins (either neutral or acid, depending upon speci? Once synthesized, the sugars in their oligosaccharide side chains) may also mucin glycoproteins are stored within cytoplasmic alter the rheological properties of mucus; for example, membrane-bound granules; and upon appropriate an increase in the acidic glycoprotein content of mucins stimulation, these granules are released via an exocyto is associated with an increase in mucus viscosity. Airway surface epithelial cells and submucosal (ii) enhanced production of mucus secondary to hyper gland cells express muscarinic receptors [23?25]. There plasia, hypertrophy or even metaplasia of the secretory is also a high density of b-adrenergic receptors on sur cells; or (iii) hypersecretion of stored mucin granules face epithelial cells and submucosal glands [26,27]. Submucosal glands also expressa-adrenergic receptors A wide variety of agents and in? Smokers with chronic bronchitis have been Mucociliary transport does not appear to be under au shown to have greater in? Cough ance of airway secretions using respiratory efforts can signal dysfunction of these components, especially designed to generate directionally opposite, but instan in chronic bronchitis, and may serve as a back-up and/ taneous, air? These depths of However, the results with hyperpnoea are consistent mucus are believed to occur in hypersecretory airway with the results observed by Bennett and colleagues, i. Following excitation of these receptors responses voluntary cough manoeuvres are ineffective in the nor include cough or deep inspirations, bronchoconstric mal airway where moderate depths of the mucus layer tion, mucus secretion and airway vasodilatation [42]. For example, following rapid abrupt changes in airway clearance of a radiomarker lung in? However, pretreatment of 0 these patients with a cholinergic antagonist that ablat 0 30 60 90 120 150 180 210 ed vagal cholinergic efferent innervation of the airway 24h and re? Assessment of mucociliary clearance on Control, mucociliary clearance as assessed with radiomarker Cough and Rapid study days; respiratory manoeuvres (high technique [46]. Final measure airway lumen and promoted hydration of the airway of radiolabel retention assessed at 24h post deposition of surface layer that favoured ef? Involuntary (spontaneous) cough is essential for clearance of secretions from the tracheobronchial air ways in elderly (over 60 years) patients with obstructive from submucosal glands onto the epithelial surface lung disease [47]. Understanding ity within central airways (trachea and stem bronchi); the linkage in obstructive lung disease between in? In general, hypersecretion of mucus within trast, in patients with advanced airway obstruction, i. However, for patients age central (a) and peripheral (b) lung clearance of insoluble with advanced airway obstruction and incapable of radiolabelled marker in healthy subjects and expiratory air generating forceful expiratory? Lung regions located by radio-gas ventilation scan and clearance is now disparate with markedly slowed divided into central (inner, 30% of total region and centred mucus layer transport within central airways [55]. For over large central airways) and peripheral (outer, remaining irritant-induced mucus hypersecretion and the later 70% of total region) airways. Time zero was at the time point stages of progressive airway obstruction, improving immediately following inhalation and deposition of the clearance of airway secretions may largely depend radiomarker. Based upon contribute to the presence of excessive mucus pro airway epithelial biopsy of mainstem bronchi the duction found in fatal asthma. Frequently on patholog epithelial mucin stores were increased in mild and ical examination, there is dilatation of the secretory moderate asthma and this increase was attributable to ducts leading from the submucosal glands into the goblet cell hyperplasia (not hypertrophy). An increase in the number of tum collected in the patients suggested that secreted epithelial goblet cells also contributes to the excess of mucin was increased only in the moderate asthmatics secretions within the airway in severe asthma [61] and [65]. An interesting observation in the diathesis of asth the excessive secretions present in the larger bronchi ma is the? When mucus secretions are in excess, in central airways are markedly reduced as compared as in status asthmaticus, mucus plugs may extend from to non-asthma subjects; and the patients (Fig. Cough and residual airways dysfunc of the airway mucus layer was now comparable with tion found to be present in asthma patients in remission lung clearance observed in unstimulated healthy sub is partly related to the presence of excessive mucus in jects [53,66]. These supranormal rates of airway question of whether excessive mucus is an important mucus clearance in mild to moderate asthmatics are cause of morbidity in moderate and mild asthmatic consistent with observations by other laboratories for (a) Normal subjects (b) Patients 12 10 10 8 8 Fig. Electrolyte and other chemical concentrations in tracheal airway a periciliary phase, adjacent to the luminal surface of surface liquid and mucus. J Appl Physiol 1989; 66: the epithelial lining cells, and a gel phase superimposed 2129?35. The thickness of this layer depends on transep 3 Knowles M, Gatzy J, Boucher R. Ion composition of air ithelial secretion of Cl across the epithelial lining cells way surface liquid of patients with cystic? J Clin Invest lated mucin secretion, and overall stability in the num 1997; 100: 2588?95. Airway and alveolar permeability and surf 2 Effective transport of the gel phase to the larynx ace liquid thickness: theory. Trans clearance of periciliary liquid and mucus from airway sur port results from coordinated ciliary activity of the face. Cough and mucociliary in mammalian trachea using an autoradiographic transport of airway particulate in chronic obstructive lung method. Measurement of the bronchial mucous gland layer vest viable tracheo-bronchial epithelial cells from living a diagnostic yardstick in chronic bronchitis. Resistance to two-phase to inhaled and intravenous carbachol in sheep: effect of gas-liquid? Mucociliary tracheal Muscarinic receptors in lung and trachea: autoradio transport rates in man. Eur Respir J 1996; 9: and frequency of causes, key components of the diagnostic 1395?401. Am J Respir versus saline solution and radioaerosol clearance in Cell Mol Biol 1995; 13: 748?56. Cough and mucociliary airway obstruction and measuring functional responses transport of airway particulate in chronic obstructive lung to bronchodilator treatment in asthma. Radionuclide mation in smokers with nonobstructive and obstructive demonstration of ventilatory abnormalities in mild chronic bronchitis. Am Rev Respir Dis 1984;129: moderate asthma is associated with airway goblet cell 989?94. Targeting of therapeu tween structural changes in small airways and pulmonary tic aerosols in asthma: is poor penetration of aerosols as function tests. Changes in changes in the peripheral airways of young cigarette mucociliary clearance during acute exacerbations of smokers. State of the art: impairment of mucociliary clearance in chronic obstruc asthma from bronchoconstriction to airways in? Scand J Respir Dis mal growth factor receptors to goblet cell production in 1976; 57: 281?9. Hele 2 Introduction Physiology the ultimate goal of an animal model is to provide the cough re? A reliable, robust and reproducible model of cough is Model development essential to pro? The chosen model should also allow the study of the physiology of cough and the mechanisms In an attempt to accurately re? Most preclinical studies Therefore a requirement of the animal of choice for of neural pathways involved in the cough re? Although many studies have been per formed in conscious rats, and cough sounds recorded As mentioned earlier, in rodents the cough re? In some species (non-rodent), a suitable depth of can be elicited in rats it would appear that the main re anaesthesia, with respiratory re? An example of this is the anaesthetized originating from the larynx can include expiration re cat, which has been utilized to analyse both the central? In other experiments cough has the Ad range, the nerves traditionally believed, along been de? It is therefore probable that investiga ineffective at initiating and may actually inhibit the tors using the model are measuring an expiration re? However, these chemical agents do elicit a cough but also in the cost of feeding and housing and in the re? These data illustrate cost of producing large quantities of drug substance for the importance of accumulating evidence from differ screening purposes. Furthermore, even development, and the cat, for example, has played a if cough can be readily elicited in a given preparation, useful role in determining the physiology and mecha the work by Canning et al. Various tussive stimuli have been examined, with the most commonly used Tussive stimuli being inhaled citric acid or capsaicin. More recent studies have uti extensively, with cough being induced in conscious lized the irritant capsaicin and low pH solutions. The larynx of most species including cat, dog, Male or female guinea-pigs have been used. Animals guinea-pig and humans is particularly sensitive to me should be housed under controlled conditions with fre chanical stimulation and even the most gentle pressure quent changes of bedding as the build-up of ammonia in this region leads to strong expiratory efforts. Furthermore, the screened to assess their level of response to the stimuli cat intrapulmonary bronchi are much more sensitive to of choice before being treated with test or standard chemical irritation and less sensitive to mechanical compound. Interestingly, sary to precondition guinea-pigs to accept aerosol ex studies have been performed in human subjects, which posure in the challenging box. The entire group of animals should then be ranked by cough response and the non-responders ex the guinea-pig model of cough cluded. The remaining animals should be blocked into high, medium and low responders and randomly as Similarity to the human cough re? The electrophysiological and me compared with its own control (prescreening) level by chanical characteristics of the cough re? The current animal of choice parisons between treated groups at the post-treatment for studying pharmacological intervention in the cough cough screening stage. The guinea-pig is then placed in a small perspex treatment with test compound or compounds can be box (approximately 1L in volume) that allows free performed at a time and by a route determined by the movement during exposure to aerosols. The three methods are as follows: 1 by observation, by an observer trained to differenti ate between coughs and sneezes and to recognize the changes in posture (splaying of the front feet and for ward stretching of the neck) and the characteristic Fig. The choice of tussive stimuli to elicit a functional coughs/min and comparisons made with prescreen response. It would appear that the ?citric acid-induced cough in Cough, irrespective of which airways disease it is asso guinea-pig model answers most if not all of these ques ciated with, represents an unmet clinical need. To achieve this end it is nec stimulus, citric acid, used to elicit cough in this model essary to develop and utilize an animal model of cough also causes cough in humans and acts on C-? Activation sponses in the same animal within a short period of time of large conductance potassium channels inhibits the and unlike repeated administration of capsaicin does afferent and efferent function of airway sensory nerves in not result in tachyphilaxis.

When feeding and swallowing skills are vulnerable mens health week nz order cheap fincar on line, careful consideration should be given to the acoustic and visual distractions in the eating area prostate oncology kalispell purchase fincar 5mg on-line, the supervision and assistance prostate 59 generic fincar 5 mg fast delivery, the level of extraneous activity androgen insensitivity hormone cheap fincar 5 mg, and the fa miliarity of personnel androgen hormone and not enough estrogen hormone fincar 5 mg free shipping, environment prostate 7 confidence inc buy fincar, equipment and routines. Pre-eating interval the purpose of structuring the pre-eating interval is to facilitate optimum perform ance during eating. Positioning/seating Correct seating for eating is important for facilitating optimum oral bolus prep aration, pharyngeal and oesophageal and bolus motility, and for comfort. When postural stability and control are problematic during eating, care should be taken to provide seats that are an appropriate size. Seat depth, height of chair back and seat height should be appropriate to allow for surfaces to stabilize trunk, hips and feet. Height of the eating surface, whether table or wheelchair lap tray, should be optimum for resting arms on the surface and for self-feeding. The plan includes any special instructions for seating and for assisting in maintaining correct upper body and head-neck alignment and stability during eating (Sheppard, 1995). The physical or occupational therapist may provide consultation for appropriate seating (Woods, 1995). Diet Diet recommendations for this population, as for other adult populations, are spe ci? In addition, recommendations may be made for liquid replacements, increasing calorie density in foods and high calorie, full nutrient supplements to compensate for swallowing and feeding de? These may include specially shaped, sized or coated spoons, forks, cups and straws as well as pads that stabilize plates, cup holders and specially designed plates. The occupational therapist may provide consultation for managing adaptive equipment and self-feeding strategies. Communication strategies Effective communication during the meal is essential for maintaining health, safety, and skills and expressing lifestyle choices. Consideration is given to the preferred modality for expression and the special needs for reception, as well as the skills of the carer as a communication partner. To achieve the goal of optimum communi cation it may be necessary to use augmentative communication systems and per sonal communication dictionaries to facilitate effective interactions during the meal (Bloomberg and Johnson, 1991; Bloomberg, 1996; McLean et al. The appropriate focus of communications during an eating activity depends on the feeding and swallowing capabilities of the individuals concerned as well as their level of communication competency. Communications may be limited to supporting calm, alert, focused attention to the eating task, or to supporting cooperative interac tions between individuals regarding the eating activity activities such as passing foods. When communication, attending, and swallowing and feeding skills permit, the content of the interactions may include social exchanges that are not directly related to the current activity. Special training for carers and patients may be needed to generate sensitivity to the effects of communication on the eating task. Tech niques used in this context are cueing strategies that assist the individual or facilitate optimum performance of the eating behaviour. A strategy is typically selected to improve one or more task components of the swallowing and feeding behaviour. They should provide a compensatory advantage, and improve overall competency in the long term i. The strategies may include assisting, touch, visual or verbal cueing, and supervising for compliance. Special techniques for dependent feeding include adaptive spooning and cup strategies that are selected to facilitate more competent oral preparation and containment of the bolus. After-eating care After-eating care may be prescribed to facilitate an increased frequency of saliva swallowing immediately following the end of the meal (Sheppard et al. Slid ing an empty, room temperature or chilled spoon in the mouth facilitates swallowing and is used for individuals who tend to cough on saliva following eating. Maintaining optimum oral hygiene is important for minimizing the risk for pul monary infection in individuals who are known to aspirate (Langmore et al. Adaptive brushing strategies may be needed in individuals with neuromuscular or sensory impairments in the mouth and pharynx in order to avoid aspiration of the oral hygiene bolus and to achieve good oral hygiene (Altabet et al. The oral hygiene plan may include stipulations for body position during brushing standing, seated or side lying, and head-neck alignment. Brushing techniques may be selected to facilitate access to the mouth, to allow the accumulating oral hygiene bolus to drain from the lips, and to assure tolerance of the procedure. The generally accepted guidelines for upright posture during swallowing and minimum of 60ml of wash down following the medication are ap propriate (Barks and Sheppard, 2005). Impairments in cog nition, attention, communication, and regulation of emotional states are common in this population. Fre quently used behavioural strategies are those that involve training during the target activity, and using cueing, feedback on performance adequacy, and reinforcement to train and maintain desired patterns of behaviour. This incidental training model has been observed to be promising for changing maladaptive eating and other swallow ing behaviours. Strategies are selected that are tolerated by the individual and have some empirical or logical support for their use. Thermal stimulation has been shown to reduce aspiration in adolescents with developmental disability. Exercise strategies, such as the Shaker exercise, which are selected to increase strength and stability in the suprahyoid muscles have been found to improve swallowing in age ing individuals (Langmore and Miller, 1994). These strategies are implemented most frequently in individu als who are designated to be given ?nil by mouth, or tube fed and on reduced oral feeding. The goals are to maintain or improve swallowing capabilities for saliva and to introduce or increase oral feeding. A range of surgical options are ap propriate including reconstructions of structures involved in swallowing to improve swallowing for oral feeding, surgical placement of a feeding tube gastrostomy or jejunostomy to substitute for, or supplement, oral feeding and as a strategy of last resort, surgical closure of the larynx. In tube-fed individuals, as in those who are fed orally, aspiration may result during ingestion of food, during swallowing of oral secretions and during reswallowing of emesis. The combination of chronic paediatric and adult onset swallowing problems are identi? Special plans may be needed for managing daily needs for eating, saliva control, oral hygiene and swallowing oral medications. In addition, dysphagia therapy pro grammes are appropriate for preventing regression and optimizing skills for swal lowing and feeding, maintaining swallowing adequacy for saliva in the tube fed individual, and for rehabilitating problems resulting from adult onset swallowing disorders. He becomes lethargic following seizure, unable to walk safely and with increased dif? He has a history of choking epi sodes that have required assistance (Heimlich manoeuvre, etc. Initially, verbal, visual and tactile cues, assistance and reduction of environmental triggers were used to shape desired behaviours. She is alert, enjoys eating, has normal food preferences and communi cates with facial gestures and vocalizations at meals. There was a recent weight loss of more than 10% of her body weight following two hospitalizations for seizures. These events raised concerns about ongoing oral feeding and resulted in referral for comprehensive team evalu ation. They were eager to participate in a nutritional management programme that might improve her chances for ongoing, successful, oral feeding. A lap-tray was available for her wheelchair; however, it was not used consistently during eating. There was laryn geal penetration of solid and liquid boluses but no aspiration on the 12 swallows that were observed on? The nutritional management plan in cluded consultation with dentist or periodontist. Paper presented at the Dysphagia Research Society Seventh Annual International Meeting, New Orleans. Reilly S, Skuse D, Poblete X (1996) Prevalence of feeding problems and oral motor dys function in children with cerebral palsy: a community survey. Paper presented at the American Speech-Language-Hearing Annual Convention, Chicago. Vinter A, Detable C (2003) Implicit learning in children and adolescents with mental retar dation. There is an important difference in these two terms and the strategies they employ to make the difference to the swallowing mechanism. We can compensate for the broken leg by using a wheelchair or a set of crutches to mobilize. On the other hand, we may wish to mobilize again by using and repairing the broken leg we want to effect permanent physiological change. There is a period of time for the bone to mend but after that time the muscles of the legs must be strengthened and a range of motion exercises employed to ensure that the limb will function as normally as possible. This is the process of rehabilitation and the end product is a resumption of function as near as pos sible to the situation before the injury. Often, individuals who go on to rehabilitation begin with a period of compensation (using crutches). Even during the initial phases of rehabilitation they may still require their crutches. Gradually the ratio changes so that the compensatory mechanisms become fewer and the reliance on the limb becomes greater as function is restored. The eventual aim is that the compensatory strategies can be dispensed with when function is restored. Whether the function is the exactly the same as it was premorbidly is not the issue, although quality of life measures may show the patient to have different views on this matter. Hopefully this demonstrates that both compensation and rehabilitation are important aspects of the recovery of function. As with the broken limb analogy, compensatory techniques are often used during the acute and/or severe phases of recovery. It would be hoped that individuals would then progress to rehabilitation in order to improve the function of the swallowing mecha nism rehabilitation of swallowing is discussed in detail in Chapter 12. However, some individuals continue to rely on compensatory techniques for the long-term. Compensation can occur in the adaptation of: Dysphagia: Foundation, Theory and Practice. When lying down, the bolus travels more slowly through the pharynx and is more likely to adhere to the posterior pharyngeal walls. In the upright posture the bolus is projected in more of an anterolateral direc tion. Note that laryngeal protective responses do not appear to be affected when swallowing occurs in either the sitting or lying postures in healthy individuals when swallowing a small volume bolus (Barkmeier et al. The thyroaytenoid mus cles are activated at the same time as or within milliseconds of activation of the sub mental complex that marks the initiation of the swallow. As yet there are no data to determine whether dysphagic individuals similarly have stable and consistent timing of laryngeal muscle onset regardless of body posture. The upright position recommended to dysphagic individuals during feeding is also important to reduce the likelihood of re? When an individual lies down, the position of the abdominal contents shifts and pushes the diaphragm upwards. If there is material in the stomach it may push up against the lower oesophgeal sphincter (the junction between the oesophagus and the stomach) and creep back into the oesophagus. Postural stability and its association with safe feeding the basic principles of eating and drinking in the upright position should not be viewed as absolute. They require sitting balance and an ability to support the head and trunk in the upright position. If individuals attention is consumed with ensuring that they won?t ?fall over, there is little room left to con centrate on swallowing. Basically the body must be supported and stable and the head should also be supported and stable. This provides the best base for the individual to be able to concentrate on swallowing. An antigravitational posture is one where the body must support and maintain a substantial portion of its own weight. When an indi vidual lies down in a recumbent or supine position, the body does not have to support its own weight. In individuals with severe disability, great effort is required to support their body weight to accomplish what healthy individuals consider as the simple act of sitting. The platform for eating is unstable and this places the individual at risk of aspiration/penetration. There are measurable physiological signs that can alert the clinician that the mere act of trying to remain upright during feeding is ?hard work for the individual. The increased pulse rate and also reports of increased respiratory rates are indica tors that the body is trying to recover the reduction in available oxygen saturation levels. They did not occur when the individuals were simply sitting upright, showing that the act of eating and swallowing places additional demands on the cardiorespiratory system. What this should tell us, then, is that even though indi viduals should be sitting in as upright a position as possible to encourage safe swal lowing, there is a delicate balance with the need to ensure that the very act of sitting does not put too much strain on the cardiopulmonary system. Dorsey (2002) found that upright positioning (70 ?90) in individuals with severe developmental disabilities was associated with aspiration. However, individuals who were supported and reclined (60 ?35) showed a reduction in aspiration. The change in posture was reported to shift the centre of balance from the pelvis up towards the trunk and shoulders. These results have implications that stretch further than the cerebral palsy and developmental dis ability populations. The clinical bottom line is that it is important that individuals be maintained in as upright a position as possible during feeding to (a) take advantage of the effects of gravity in propelling the bolus into the oesophagus, and (b) to make it harder for re? However, where indi viduals are unable to support their head and/or trunk comfortably, measures must be taken to allow head and/or trunk support to occur. This may involve progressively reclining the chair/bed to an angle that best allows the body to be supported and reduce the ?physiological load during eating. These head postures are compensatory because, if effec tive, they should be employed for each and every swallow.