Lamictal

Marc J. Poulin, PhD

• Professor, Department of Medicine and Department
• of Physiology and Biophysics, Faculty of Medicine,
• University of Calgary, Calgary, Canada

Major fetal anomalies such as fetal hydrops treatment warts purchase lamictal 100mg fast delivery, anencephaly medications you can take while breastfeeding buy lamictal 100 mg line, body stalk anomaly crohns medications 6mp generic 50mg lamictal with amex, large anterior abdominal wall defects treatment of pneumonia order cheap lamictal online, megacystis symptoms colon cancer buy lamictal 100 mg lowest price, and others (see Table 5 hair treatment purchase lamictal with visa. With accumulating knowledge and expanding expertise, the approach to the first trimester ultrasound has changed over time. Advantages of the fetal anatomic survey in the first trimester include the ability to image the fetus in its entirety in one view, lack of bone ossification which obstructs view later in gestation, increased fetal mobility, which allows imaging from many different angles, and the availability of high-resolution transvaginal ultrasound, which brings the ultrasound transducer in proximity to fetal organs. Challenges of the first trimester anatomic survey however include the need to combine the abdominal and transvaginal approach in some cases, the small size of fetal organs, and the lack of some sonographic markers of fetal abnormalities that are commonly seen in the second trimester of pregnancy. In our experience, the performance of the fetal anatomic survey in the first trimester is enhanced if a systematic approach is employed. We coined the term detailed to reflect on the comprehensive nature of this approach to fetal anatomy in the first trimester. It is important to emphasize that the performance of the detailed first trimester ultrasound examination requires substantial operator expertise in obstetric sonography, high-resolution ultrasound equipment, and knowledge of the current literature on this subject. Optimizing the first trimester ultrasound examination as described in Chapter 3 of this book, along with the use of the transvaginal approach with color Doppler and three-dimensional (3D) ultrasound when clinically indicated, will enhance its accuracy. I n Chapter 1, we listed existing national and international guidelines for the performance of the first trimester ultrasound examination. The systematic approach that is proposed in this chapter expands on existing guidelines and is geared toward a detailed evaluation of fetal anatomy in early gestation. We have developed this approach to the detailed first trimester ultrasound over several years and have found it to be effective in screening for fetal malformations in early gestation. Undoubtedly, as new information comes about and with technological advances in ultrasound imaging, the approach to the detailed first trimester ultrasound examination will evolve over time. Only few studies reported on the early gestation detection of fetal malformations in large screening populations with ultrasound examinations performed by several 1 examiners with various level of expertise. The authors classified the type of first trimester fetal malformations into four main groups: always detectable, occasionally detectable, rarely detectable 1 1 and non-detectable. In our experience, there are four main pathways that result in the prenatal diagnosis of fetal malformations in the first trimester: 1. This approach has led to the first trimester diagnosis of complex cardiac, brain, skeletal, gastrointestinal, and genitourinary anomalies as presented in various chapters in this book. Pregnancies at High Risk for Fetal Malformations: When the pregnancy is at high risk for fetal anomaly due to a prior history of an affected child or due to a known inheritance pattern of a specific malformation, a detailed ultrasound in the first trimester can identify the fetal malformation. Examples include a pregnancy with prior spina bifida, an autosomal recessive inheritance pattern identified in a prior pregnancy, or an autosomal dominant inheritance pattern present in one of the parents. The presence of subtle findings in the first trimester ultrasound can be of significance in such cases such as the presence of abnormal intracranial translucency, polydactyly, echogenic kidneys, skeletal abnormalities, and cleft lip and palate, among others. Several of these subtle findings are discussed in detail in various chapters in this book. Detailed First Trimester Ultrasound in Low-Risk Pregnancies: the detection of fetal malformations in the first trimester can also be the result of a detailed ultrasound examination that 11, 13, 19 is routinely performed beyond the 11th week of gestation. With increasing skills and expertise in the detailed first trimester ultrasound, sonographers and sonologists may decide to apply this approach to all first trimester pregnancies beyond the 11th week of gestation for fetal anomaly screening. The detailed first trimester ultrasound will thus be an adjunct to the second trimester ultrasound examination. It is important to note however that several limitations currently exist to the detailed first trimester ultrasound examination and it is thus important to list these limitations before its introduction. In such conditions, the use of the transvaginal approach or a repeat ultrasound examination at 16 weeks of gestation either with a transabdominal high-resolution linear probe or with the transvaginal approach, if feasible, may provide sufficient access to assess fetal anatomy in detail. Occasionally, however, transient maternal contractions may trap the fetus in one area of the uterus and limit ultrasound accessibility. In our experience, rescanning the patient 15 to 30 minutes later provides for a better access, because in most cases the uterine contractions will have resolved (Fig. Indirect Signs of Fetal Malformations Another limitation of the detailed first trimester ultrasound examination is the absence of classic, indirect signs of fetal malformations that are commonly seen in the second trimester. For instance, unlike in the second trimester, bilateral renal agenesis is commonly associated with normal amniotic fluid volume in early gestation and open spina bifida does not typically display a lemon or banana sign in the first trimester as is very often seen in the second trimester of pregnancy. Furthermore, fetal biometric changes and growth restriction that are commonly associated with fetal malformations do not manifest in early gestation and cannot be used as clues to the presence of associated malformations. It is important to note for all these reasons and others that the detailed first trimester ultrasound examination for fetal anatomy survey does not replace the traditional second trimester ultrasound but rather is complementary to it, especially in a high-risk pregnancy. We were not able to complete the ultrasound examination despite an attempt by the transvaginal approach. The ultrasound examination was repeated 35 minutes later (B), which showed resolution of the contraction, optimization of imaging, and the fetus moving freely within the uterine cavity. Time in Gestation of Development of Certain Malformations It is important to note that a major limitation of the detailed first trimester ultrasound examination for fetal anatomy survey is that some ultrasound findings that are seen in early gestation may disappear upon follow-up into the second trimester of pregnancy. On the other hand, some malformations that are traditionally visible in the second trimester, such as cystic lesions of lungs and kidneys, cardiac valvular stenosis, cortical brain abnormalities, cerebellar vermis dysgenesis, agenesis of corpus callosum, gastrointestinal atresias, and others are commonly associated with normal ultrasound findings in early gestation. It is therefore important for the sonographers and sonologists to be familiar with the natural course of congenital malformations and counsel patients regarding limitations of the first trimester ultrasound examination in that regard. Safety Aspects the detailed first trimester ultrasound examination is performed during a period of development and rapid growth of fetal organs. It is thus critical to minimize ultrasound exposure to the fetus, especially the use of pulsed Doppler, given its associated high energy. The risk of fetal exposure to ultrasound energy should always be balanced against the benefit of the ultrasound examination in early gestation. Refer to Chapter 2 of this book for a comprehensive discussion on ultrasound bioeffects and safety. As stated in the Introduction section of this chapter, the detailed first trimester ultrasound is performed at 11 to 14 weeks of gestation. Components of the detailed first trimester ultrasound examination include general overview and fetal biometry, comprehensive evaluation of fetal anatomy, and an assessment of the uterus and adnexal regions. This detailed first trimester ultrasound examination is not intended to replace the traditional second trimester ultrasound but rather to complement it, and in the majority of pregnancies to provide early reassurance of normalcy. The three components of the detailed first trimester ultrasound are described in the following sections of this chapter. General Overview and Fetal Biometry Initial aspects of the first trimester ultrasound include the confirmation of the location of the gestational sac within the endometrial cavity, the presence of cardiac activity, and the number of fetuses. This can be easily accomplished by the abdominal ultrasound, but on occasions may require the transvaginal approach. In pregnancies with prior cesarean sections, the scar is 20 ideally assessed by transvaginal ultrasound. In these pregnancies the location of the gestational sac within the endometrial cavity should be noted and implantations in the lower uterine segment should 21, 22 raise suspicion for increased risk for placenta accreta (see Chapter 15). Furthermore, implantation of the gestational sac in the cesarean scar (cesarean scar implantation) is of significant 22, 23 importance given its association with placenta accreta and serious pregnancy complications. In the presence of twins or higher order multiple pregnancy, determining the chorionicity and amnionicity in the first trimester is of paramount importance. Note that the placenta (P) is a previa in this pregnancy as it is shown to cover the internal cervical os (asterisk). The presence of placenta previa in the first trimester is of little clinical significance and should be followed up in the second trimester of pregnancy. Any significant discrepancy in biometric measurements should alert for the possible presence of anatomic abnormalities or genetic malformations. First trimester fetal biometry and pregnancy dating are discussed in detail in Chapter 4. Comprehensive Assessment of Fetal Anatomy the comprehensive assessment of fetal anatomy is an important component of the detailed first trimester ultrasound. This approach to fetal anatomy in early gestation involves multiple sagittal, axial, and coronal planes of the fetus. Acquiring the technical skills required for the display of the corresponding anatomic planes and an in-depth knowledge of the current literature on this subject are prerequisites for the performance of the detailed first trimester ultrasound examination. In this section, we present our systematic approach to the assessment of fetal anatomy in the detailed first trimester ultrasound examination. General Anatomic Assessment the initial step of the fetal anatomy survey in the first trimester involves obtaining an anterior midsagittal plane of the fetus when technically feasible. This midsagittal plane allows for a general anatomic assessment, given that the whole fetus is commonly included in this plane (Fig. This midsagittal plane displays several important anatomic landmarks, which are listed in Table 5. In this midsagittal plane, the size and proportions of the fetal head, chest, and body are subjectively assessed and the following anatomic regions are recognized: fetal facial profile and midline intracranial structures, the anterior abdominal wall, the fetal stomach, and bladder. By slightly tilting the transducer from the midline to the left and right parasagittal planes, the arms and legs can be visualized. Many of the severe fetal malformations that can be detected in the first trimester (Table 5. When clinically indicated, color and pulsed Doppler interrogation of the ductus venosus is also best assessed in this midsagittal plane. The Fetal Head and Neck Evaluation of the anatomy of the fetal head and neck in the first trimester requires imaging from the midsagittal, axial, and coronal planes. Normal anatomic features of the midsagittal plane of the head and neck are shown in Figure 5. Abnormalities that can be detected in this plane include anencephaly, holoprosencephaly, anterior cephalocele, proboscis, absent nasal bone, maxillary gap or protrusion (associated with cleft palate), epignathus, retrognathia, and others. Abnormalities that can be detected in the midsagittal plane of the facial profile are described and illustrated in Chapter 9. Abnormalities that can be detected by the midsagittal plane of the posterior fossa are presented and illustrated in Chapter 8. No structure Forehead protruding Nasal region Nose present and nasal bone ossified Maxilla No maxillary gap, no protrusion Mouth Upper and lower lips appear normal Mandible Normal appearance, no retrognathia Both eyes In coronal plane, eyes seen with the nose between Retronasal triangle In coronal plane, no cleft and normal mandibular gap Axial Planes From the midsagittal plane, the transducer is rotated 90 degrees to get the axial planes of the fetal head, ideally imaged from the lateral aspects. These planes include the axial plane at the level of the lateral ventricles, the axial plane at the level of the thalami, the axial-oblique plane at the level of the cerebellum and posterior fossa, and the axial plane at the level of the orbits. Normal anatomic features of these four axial planes of the fetal head are shown in Figures 5. The choroid plexuses are often asymmetrical and touch the lateral and medial borders of the ventricles and their area is between 50% and 75% of the areas of the ventricles (Fig. In this plane, the hourglass shape of the fourth ventricle and its choroid plexus is best visualized along with the developing cisterna magna (Fig. Abnormalities that can be detected by these axial planes of the fetal head include anencephaly, holoprosencephaly, ventriculomegaly, encephalocele, open spina bifida, and some severe eyes and face anomalies as described and illustrated in Chapters 8 and 9. The (plane 2) aqueduct is not stuck to the occipital bone Visualized with choroid plexus of fourth ventricle, hourglass Fourth ventricle (plane 3) shape In anterior axial planes, two orbits with eyes are visualized Eyes (plane 4) with the nose arising between Some details are better seen on transvaginal ultrasound. Planes 1 and 2 are obtained from fetuses at 13 weeks of gestation and examined by the transabdominal linear probe. Coronal Plane In an oblique coronal plane of the face, the eyes, orbits, and the retronasal triangle consisting of the nasal bones, the maxillary processes, and the anterior maxilla with the alveolar ridge can be recognized (Fig. The coronal plane of the face is helpful in the detection of severe anomalies of the eyes, large facial clefts, and retrognathia/micrognathia. A more comprehensive discussion of the normal and abnormal facial anatomy is presented in Chapter 9. The Fetal Chest and Heart the detailed first trimester ultrasound examination of the fetal chest is best performed by two axial planes and one coronal plane. The two axial planes are most informative when the fetus is in a dorsoposterior position in the uterus and the coronal plane is primarily for the assessment of the diaphragm. Color Doppler helps to confirm the presence of two distinct ventricles with separate filling in diastole and the absence of significant atrioventricular valve regurgitation (Fig. When indicated, pulsed Doppler can assess for the presence or absence of tricuspid valve regurgitation. An abnormal cardiac axis or 24 abnormal cardiac position in the chest is associated with cardiac malformations or a diaphragmatic hernia. Abnormalities that can be detected in this plane include hypoplastic left or right ventricle, single ventricle, ventricular disproportion, large septal defects, arrhythmias, pericardial effusion, diaphragmatic hernia, and others. Cardiac axis can also be measured in this plane and adding color Doppler facilitates its measurement (B). Plane 2 is best obtained in color Doppler showing the pulmonary artery, the aorta, the superior vena cava, and the trachea. This plane allows for the detection of complex cardiac anomalies in the first trimester. The V-shape of the great vessels with a course left to the echogenic trachea can be recognized (Fig. If needed, this plane can also be used to demonstrate the normal or aberrant course of the right subclavian artery by applying color Doppler at low velocity scale. A more comprehensive discussion of the normal and abnormal cardiac anatomy is presented in Chapter 11. Coronal Plane If a diaphragmatic hernia is suspected in the axial plane or has to be ruled out, the lungs and diaphragm are better imaged in a coronal plane slightly anterior to the spine and ribs (Fig. In this plane, the relationship of the stomach, diaphragm, and lungs can be easily evaluated.

Prognosis Children with more extensive leptomeningeal involvement or bilateral disease have a worse prognosis symptoms hiatal hernia buy lamictal online. Ataxia telangiectasia Epidemiology 1:40 7 medications that cause incontinence order lamictal 100mg on line, 000 professional english medicine buy generic lamictal 100mg on line, autosomal recessive or sporadic mutation in chromosome 11q23 medications equivalent to asmanex inhaler order cheapest lamictal. Prognosis Death can occur in late childhood or early teens but many with appro priate supportive care will live well into adult life 247 medications purchase lamictal 100mg with mastercard. Cysts form around these tumours and the cyst is often far greater in size than the tumour treatment wax discount 25mg lamictal overnight delivery. Phaeochromocytoma, angiomas of the liver and kidney, papillary cystad enomas, and endolymphatic sac tumours all occur with greater frequency. Regular ophthalmological examination to follow small retinal haemangioblastoma is appropriate, but if visual loss or retinal detachment occurs then this may be treated with laser photocoagulation or cryocoagulation. Linear sebaceous nevus/epidermal nevus syndrome A midline or near midline yellow-brown hairless plaque occurs on the face or scalp at birth or in early childhood which may become malignant. These conditions are listed by most typical age at onset, and are all discussed in more detail on subsequent pages. In these situations, the main implications of diagnosis may be for family members other than the index case. Traditionally the classical and more severe connatal forms are distinguished by rate of progression, though there is considerable overlap. Treatment now includes enzyme replacement and substrate inhibition therapies, though these do not seem to halt neurological deterioration. This contrasts with the presentation more typical of adult-onset disease of progressive dementia with prominent psychiatric symptoms, tremor, chorea and late seizures. Wilson disease (hepato-lenticular degeneration) Consider this in all unexplained neurological regression and personality change as the neurological deterioration is preventable. It is a recessively inherited defect of copper transport resulting in deposition in the brain, liver, and cornea. If there is any doubt, proceed to penicillamine challenge, increased copper on liver biopsy. Hereditary spastic paraparesis A heterogeneous group of conditions characterized by spastic paraparesis progressing slowly over years typically with onset in teens or twenties (but can be much earlier). Supportive care for neurodegenerative conditions Even if cure is not possible there is much we can do to help: See b p 3, general advice. Always offer to meet with the family again after the child eventually dies to address unresolved issues they may have. Neurotransmitters have wide-ranging effects, regulating neurons involved in memory and cognition, motor function, temperature, balance and pain. Exercise depletes dopamine; rest replenishes; if it cannot be replenished, the movement disorder will be kinesogenic, i. International classi cation of sleep disorders American Academy of Sleep Medicine. Parasomnias Recurrent episodes of behaviour, experiences or physiological changes that occur exclusively or predominantly during sleep. Susceptibility often runs in families with children moving from one arousal disorder to another as they develop. The error is understandable: frontal lobe seizures often com prise loud cries or shrieks and violent pedalling or thrashing movements of the limbs that do not conform to conventional notions of seizure phenomenology. An overnight video is crucial in cases of uncertainty but the onset of the attack must be captured to be informative. Excessive daytime sleepiness (hypersomnia) Most commonly re ect insuf ciently restful, poor quality night-time sleep. Clinical features There is a highly individual patient symptom pro le creating potential diagnostic dif culties. Studies have shown that the diagnosis is only cor rectly made in 38% of patients with narcolepsy prior to evaluation by a sleep specialist. The need for a daytime nap continues after the toddler age group; night-time sleep is not restless or disturbed, behaviour disturbance not expected. Impractical in young children (under 10) and there are no normative paediatric data. Assesses how long a patient can stay awake in a comfy chair sat in a quiet dark room. It is essential not to base the diagnosis of narcolepsy on the result of a single test. Imaging will show radiological changes typical of infarction but this is typically multifocal and not con ned to single vascular anatomical territories. Adult trials suggest a window of up to four hours from the stroke but even in this group the routine use of throm bolysis remains unestablished. Within the arterial ischaemic group, consider ation of lesion location in relation to vascular territories (see b p. Recommendations based on these guidelines are indicated later with an asterisk (*). This may be relaxed after 3 yrs to maintain HbS < 50% and stopped after 2 yrs in patients who experienced stroke in the context of a precipitating illness. Common presentations Presentation depends on the age of the child and the location of the tumour. Over expression of p53 and glioblastoma multiforme are associated with poor prognosis. Further intensi cation of chemotherapeutic regimens with autologous bone marrow or peripheral stem cell reconstitution is being evaluated in children. Mainstay of adjuvant treatment is focal radiotherapy to tumour bed, certainly in over-3s. Children should have supplemental steroids before surgery and prior to treating hypothyroidism. Myeloablative chemotherapy or chemoradiotherapy followed by autologous bone marrow transplantation is under investigation for the high risk group. This section, however, deals mainly with inborn errors of metabolism that may be thought of as treatable early epileptic encephalopathies. Outcome Life-long treatment; likely learning dif culties, particularly language delay; more severe motor disorder and developmental delay if treatment is delayed. In such cases withdrawal of pyridoxine to con rm dependency is no longer recommended. Pre-symptomatic diagnosis of B12 de ciency following identi cation of a megaloblastic anaemia is typical, however late diagnosis can result in neurological damage. This has led to debate about the wisdom of introduction of folate forti cation of our as a public-health measure to prevent neural tube defects (by ensuring adequate folate levels in women in the early days of pregnancy during neural tube forma tion); as folate supplementation will treat megaloblastic anaemia. As folate metabolism is closely linked to B12 metabolism, not surprisingly clinical features are similar. Vitamin E this is a generic term for a group of related compounds (tocopherols and tocotrienols). Neurological conditions responsive to vitamin E can be considered as two groups: conditions of vitamin E de ciency and conditions of increased stress on antioxidant protection. Studies have indicated that vitamin E supplementation decreases the incidence of intraventricular haemorrhage and of retinopathy of prematurity in pre-terms, but may increase the risk of sepsis and necrotizing enterocolitis by impairing normal oxygen dependent antimicrobial defences. Prophylactic vitamin E is not currently recommended, while the risk/bene t ratio remains unclear. Untreated they develop ataxia, peripheral neuropathy and retinal degeneration leading to blindness; high dose supplementation prevents, delays progression or reverses these neurological features (A-tocopheryl acetate 100 mg/kg/day). Vitamin E, folinic acid and antioxidant supplementation in Down syndrome has not shown bene t in terms of psychomotor development. Biotin metabolism Biotin is a B-group vitamin, essential for covalently binding to carboxylase enzymes (enzymes that have a central role in gluconeogenesis, in amino acid metabolism and in fatty acid biosynthesis for the Kreb cycle). Remember non-neurological colleagues may have adopted a less skilled clinical approach; it is always best to repeat the detail of the history and carry out your own neurological examination. Ensure the referrer appreciates the importance of consid ering other, non-neurological perspectives on the problem on which you were consulted. Periventricular white matter injury in young infants associated with late neurocognitive de cits. Early cerebral palsy typically shows milder hypotonia and antigravity muscle weakness. Cyclical vomiting Repeated bouts of vomiting lasting hours to days usually occurring at a characteristic time of day for the child: can result in severe electrolyte imbalance. Both are diagnoses of exclusion (easier to be con dent of diagnosis in recurrent episodes).

Holes resulting from trauma may often show evidence of remodelling if the victim survived for any length of time after the event and will not have undercut edges symptoms of dehydration discount lamictal 100 mg overnight delivery. In all such cases shinee symptoms mp3 purchase 200 mg lamictal visa, the bones should be X-rayed when the presence of areas of sclerosis will be apparent if metastases are present treatment 1st degree av block purchase discount lamictal. Although kidney and thyroid tumours show a marked tendency to metastasise to bone medicine reviews discount lamictal 100mg, their incidence is much lower than the other tumours and so they are less likely to be present on this account (see Table 9 medications you cant drink alcohol with buy 25mg lamictal with amex. There is nothing to dis tinguish them with any certainty from the other lytic tumours medications on a plane generic lamictal 25 mg fast delivery, however, or from myelomatosis for that matter, and in the end, the nal decision has to be made on probabilistic grounds. Skeletal pathologists are likely to be less helpful because their expertise lies primarily in diagnosing bone tumours from their histology and it is unlikely in the extreme that any material that would interest them will survive. Even with all the help that one can muster, however, it is almost certain that a substantial number of the tumours that may be found in the skeleton will not receive a de nitive diagnosis. Growth and development is an area to which the study of skele tal assemblages is able to make a signi cant contribution. It is, however, more prolonged and is the period during which most height is gained. Differences have, of course, been found, with several cycles of changes in height noticed both in Europe and North America and attempts have been made to relate these to availability of food, wars and other environmental or social in uences. Comparison between skeletal populations, however, is perfectly valid so long as the same regression equations (and the same bone) are used for the purpose. Actually, in his paper he used the term mediocrity rather than median, but the median was what he was describing. For the complete data set see: K Sproston and P Primatesta (editors), Health survey of England 2003, London, the Stationary Of ce, 2005. It would be very interesting to know the speed at which children developed in the past as this would provide some insight into the state of nutrition at different historical periods. The average rate of growth per year can then be calculated and the results of such studies are widely used by paediatricians to determine both normal and abnormal rates of growth in their patients. See also, B Bogin, Patterns of human growth, Cambridge, Cambridge University Press, 1999. Diagram to show four hypothetical cohorts of children having been born at different times (shown in arbitrary units on the x-axis) and with slightly different growth rates (shown in arbitrary units on the y-axis). Children available for study (shown as solid circles on A, B, C and D) will come from the whole assemblage and would originally have formed part of one of other of the original cohorts. The children studied will come from all periods represented in the assemblage and will have originally belonged to several cohorts. The growth curve constructed from the results will include data from children scattered throughout the period and will not truly represent any of the actual growth curves and this cross-sectional growth curve will not be able to distinguish any uctuations that may have taken place over the study period. It follows that any comparison with modern growth rates will be completely invalid. The rst two conditions are associated with skeletal abnormalities whereas the last two are not. The hormone is secreted by one of several groups of cells in the anterior pituitary that produce hormones in response to stimulating factors released from the hypothala mus. In a child, it might not be possible to distinguish it from one whose growth had been stunted by severe malnutrition, except that the latter might show evidence of osteoporosis. If even this were dif cult, then the only alternative may be to utilise data from modern children although this would be the least favourable option. The dysplasias are characterised by the following: r Abnormal shape or size of the skeleton; r Increased or decreased number of skeletal elements; and r Abnormal bone texture as the result of an increase or decrease in bone remodelling and mineral deposition. The trunk is usually normal although the thorax may be narrow due to shortening of the ribs. If the extra digit is on the radial or tibial side it is said to be pre-axial, if it is on the ulnar or bular side, it is post-axial. Syndactyly refers to the fusion of digits, while clinodactyly refers to deviation of the ngers which would be dif cult to detect in the skeleton. There may be a number of changes in the skull including scaphocephaly (a long, at skull) and brachycephaly (a short, broad skull). Note that the incidence will depend to a large extent on the population being sampled. In all types, fractures are common, most frequently in the lower limbs and they are usually transverse. Dental anomalies are common, including small or abnormally shaped teeth, and congenitally missing teeth. The number of exostoses (osteochondromas) is variable, but tends to increase up to about the age of 12 and as many as one hundred may be present. There are several variants some of which are autosomal recessive and some autosomal dominant, the latter variants being more benign than the former (see Table 10. The bone marrow cavities are obliterated causing de cient haematopoiesis, recurrent infections and early death. Individuals with the recessive intermediate type are of short stature and prone to fractures. An autosomal dominant form was the rst to be described by Albers-Schonberg 49 and the condition is still referred to as Albers-Schonberg disease, especially in the older texts. Radiographs will show diffuse sclerosis, especially in the cranial vault as a solitary nding (type I). Hypoplasia of the ulnas and bulas is very marked and the radii and tibias are short, thick and noticeably curved. It is attached to the medial side of the distal radius and may be recognised in the skeleton by the appearance of a cortical defect in this position. Before a short skeleton is labelled as that of a dwarf, care must be taken to ensure that it falls outside the fth centile of the appropriate age and sex standardised distribution, or more than three standard deviations from the mean. In some cases the tumour may cause the pituitary fossa to become enlarged and this may be seen directly, if the skull is broken, or by X-raying the skull. He was very anxious that he should not fall into the hands of the anatomists when he died and left a large sum of money to ensure that he was buried at sea. AnX-rayoftheskullshows an enlarged pituitary fossa indicating that Byrne did indeed have a pituitary tumour. In the skeleton, the diagnosis would depend on nding a skeleton with an enlarged jaw and supraorbital ridges, large hands and feet and, if possible, radiographic evidence of an enlarged pituitary fossa. Disorders of Skull Growth Disorders of skull growth cause it to be either very small or very large, or of abnormal shape due to the premature closure of the sutures. Microcephaly and macrocephaly: Microcephaly and macrocephaly are generally said to be present when the head is either two standard deviations below or above the appropriate age and sex-standardised mean; some paediatricians prefer to use a de nition of minus three standard deviations to diagnose microcephaly. If present at birth, it is termed primary, and secondary if it develops later in childhood; there are a number of genetic and environmental causes and it may also occur with pansynostosis. Ideally, these data should be derived from other skeletons from the same assemblage, or those from other assemblages from similar times and places. The abnormality in skull shape depends upon which of the sutures is prematurely fused, and the principal changes are shown in Table 10. Principal changes in the skull in craniosynostosis Type of craniosynostosis Sutures prematurely fused Principal changes in the skull Scaphocephaly Sagittal Elongation of the skull with bitemporoparietal narrowing and frontal and occipital bossing. Frontal plagiocephaly Left or right coronal Flattening of forehead on affected side with contralateral frontal bossing. Occipital plagiocephaly Left or right lambdoid Ipsilateral occipitoparietal attening with contralateral parietal bossing and contralateral frontal bossing. In life, the cleft may be partial or complete, in which case it involves the maxilla and the lip. Developmental Disorders of the Hips There are three developmental disorders of the hips that affect children and adoles cents and which may persist into adulthood without appropriate treatment, as would have been the case for the greater part of the period with which palaeopathologists are concerned. There are several known risk factors including family history, breech presentation and post-natal swaddling. Thelefthipisaffectedaboutfour times more commonly than the right but the condition may also be bilateral. In a typical case one or both acetabula will be hypoplastic or obliterated altogether. The pseudarthrosis are often large, surrounded by new bone and they will frequently be eburnated as will the femoral heads. It manifests itself around the onset of puberty, particularly in overweight males who are about three times as likely to have the condition as females. The condition has no preference as to side and is bilateral in about a quarter of cases. It is not clear what causes the fracture, 88 although trauma and activity are thought to play a part. Whatever the aetiology, the result is that the epiphysis is displaced posteriorly and medially with a reduction in the anteroposterior neck-shaft angle. These changes are referred to as a tilt deformity (D Resnick, Patterns of migration of the femoral head in osteoarthritis of the hip. The condition passes through four stages: (1) the onset of avascular necrosis; (2) fragmentation of the head of the femur; (3) revascularisation and regeneration; and (4) healing. X-rays of affected bones should showlucent areas with endosteal scalloping and sometimes, a thick sclerotic border, the so-called rind sign. Kyphosis and Scoliosis Kyphosis refers to a forward curvature in the spine in the anteroposterior plane. There are several causes of scoliosis107 and there is also an association with the Klippel-Feil syndrome108 (see below) but the most common type, accounting for up to 80% of all cases, is the so called idiopathic form. This results in the characteristic humped back and narrowing of the thoracic cage. Theribsareoftenthinnerthan normal and the vertebrae are wedged towards the concave side and osteophytes are often present together with osteoarthritis of the costo-vertebral joints. There are a number of vertebral anomalies that may cause scoliosis including partial or complete unilateral failure of formation, resulting in wedged or hemi-vertebrae, and failure of segmentation which may be partial or complete. In this method, the proximal and distal end vertebrae are delineated, these being the vertebrae at the upper and lower limits of the curve and which tilt most towards its concavity. The Cobb angle can easily be determined on skeletons with scoliosisafterthevertebraehavebeenarticulatedand xedinposition. Cases occur in skeletal assemblages and there is no dif culty whatsoever in recog nising them for what they are; however, in some assemblages they seem to be somewhat under-represented. At Christ Church, Spital elds, for example, the crude prevalencewaslessthan1% but by contrast, Wells reported on an assemblage of 50 skeletons recovered from the church of St Michael-at-Thorn in Norwich. Only eight had well-preserved spines and of these, two had scoliosis, both females. Klippel-Feil Syndrome the original syndrome described by Klippel and Feil in 1912 was a triad comprising a short neck, low hairline and limited movement of the neck. Cervical rib: the anterior element of the transverse process of the seventh cervical vertebra is the homologue of the rib in the thoracic region and it sometimes develops to form a cervical rib of variable length. Spina bi da occulta: Spina bi da occulta is the term used to describe a sacrum in which all the laminae are unfused. The prevalence is considerable, 8% in one skeletal assemblage123 and 11% in a series of unselected radiographs.

The proportion of abortions performed in hospitals has steadily declined medications 4 less safe lamictal 50mg, reaching 7% in 1992 treatment 001 order lamictal 50 mg mastercard. Possible explanations include a reduction in unintended pregnancies (better contraception) and a greater willingness to experience a pregnancy; however medicine administration cheap lamictal 50 mg line, another possibility is reduced access to abortion services symptoms queasy stomach buy 50mg lamictal visa. American teenagers are especially dependent on abortion compared with their European counterparts who are better educated about sex and use contraception more 104 often and more effectively medications zanx purchase lamictal 50mg fast delivery. The lack of perfect contraception and imperfect use of contraception will keep abortion with us symptoms vs signs purchase 25mg lamictal with mastercard. Public health authorities have demonstrated that the legalization of abortion reduced maternal morbidity and mortality more than any single development since the advent of antibiotics to treat puerperal infections and blood banking to treat hemorrhage. The number of American women reported as dying from abortion declined 108 from nearly 300 deaths in 1961, to only 6 in 1985 and 11 in 1991, or about 0. For comparison, in 1990, the maternal 108, 109, 110 death rate for childbirth in the U. More experienced surgeons and younger, healthier women are less likely to have complications. There is no evidence for any adverse consequences of 116, 117 118, 119 120, 121 vacuum aspiration abortion for subsequent fertility, pregnancies, or increased risk for ectopic pregnancy. It is not yet clear if second-trimester abortions or several first-trimester abortions can affect the outcome of later pregnancies. A French study disagrees with these conclusions, finding 124 a slightly increased risk of ectopic pregnancy in women with a prior induced abortion and no previous ectopic pregnancy. However, multiple induced abortions do not increase the risk of a subsequent 122 123 ectopic pregnancy. The unequivocal evidence indicates that depression is less frequent among women postabortion compared with postpartum, that women denied abortion experience resentment for years, and that the children born after abortion is denied have social, 125 occupational, and interpersonal difficulties lasting into early adulthood. Conflicting results have been reported in over 20 studies examining the risk of breast cancer associated with the number of abortions (especially induced abortions) 126, 127 experienced by individual patients. Concern for an adverse effect has been based on the theoretical suggestion that a full-term pregnancy protects against breast cancer by invoking complete differentiation of breast cells, but abortion increases the risk by allowing breast cell proliferation in the first-trimester of pregnancy, but not allowing the full differentiation that occurs in later pregnancy. Family planning services that provide effective contraceptive choices as well as access to safe abortion early in pregnancy are essential in order for societies to achieve desired fertility rates and a healthy female population. During the 108 first-trimester, abortion morbidity and mortality rates are less than one tenth those of abortions performed in the later midtrimester. The vast majority of these operations occur in free-standing abortion clinics, although in recent years, physicians have performed larger numbers in their offices where women are less subject 103 to the harassment that has plagued clinics. The care of the patient who has decided to terminate a pregnancy begins with the diagnosis of intrauterine pregnancy and an accurate estimate of gestational age. Failure to accomplish this is the most common source of abortion complications and subsequent litigation. Tests for pregnancy, including vaginal ultrasound, should be used when accuracy is difficult. Nearly all women who want to terminate a pregnancy in the first-trimester are good candidates for an outpatient procedure under local anesthesia. Possible exceptions include patients with severe cardiorespiratory disease, severe anemias or coagulopathies, mental disorders severe enough to preclude cooperation, and excessive concern about operative pain that is not alleviated by reassurance. Abortions should not be undertaken for women who have known uterine anomalies or leiomyomata or who have previously had difficult first-trimester abortion procedures, unless ultrasonography is immediately available and the surgeon is experienced in its intraoperative use. Previous cesarean section or other pelvic surgery is not a contraindication to outpatient first-trimester abortion. Counseling Abortion Patients 132 Counseling has played a critical role in the development of efficient and acceptable abortion services. These include help with decision making, provision of information about the procedure, obtaining informed consent, provision of emotional support for the patient and her family before, during, and after the operation, and 133 providing information about contraception. Referral opportunities should be provided for prenatal care or adoption for women who choose to carry an unplanned pregnancy to term. These responsibilities can be performed by a physician, nurse, psychologist, social worker, or a trained lay person. An informed consent document should unequivocally state the possibilities of common adverse outcomes, such as incomplete abortion, infection, uterine perforation, the need for laparotomy, ectopic pregnancy, and failed abortion. The counselor should document that all preoperative responsibilities have been discharged. Methods for First-Trimester Abortions 105 the most widely used technique for first-trimester abortions is vacuum curettage (99% of legal induced abortions in 1995). These are osmotic dilators of dried seaweed or synthetic hydrophilic substances that are left in place from a few hours (synthetic) to overnight (seaweed). Aspiration abortion is safe and effective, but it is not available everywhere, and some women find it difficult to undergo a surgical procedure or to go to a clinic where they may be subject to loss of privacy or harassment. Nonsurgical methods might make abortion available to more women and improve the circumstances under which pregnancies are terminated. France and China were the first countries to approve the marketing of the medical abortifacient mifepristone (now available in Great Britain and Sweden as well), a synthetic relative of the progestational agents in oral contraceptives. Both progesterone and mifepristone form hormone-responsive element-receptor complexes that are similar, but the mifepristone complex has a slightly different conformational change (in the hormone-binding domain) that prevents full gene activation. The agonistic activity of this progestin antagonist is due to its ability to activate certain, but not all, of the transcription activation functions on the progesterone receptor. There are three major characteristics of its action that are important: a long half-life, high affinity for the progesterone receptor, and active metabolites. A single 600 mg oral dose of mifepristone is followed a day later by the administration of a prostaglandin analogue. Several analogues have been used, but the most 135 widely available and best tolerated is misoprostol, 800 mg administered vaginally. When 136 administered in the first 8 weeks of pregnancy, this medical termination carries success and complication rates similar to that achieved with vacuum curettage. Misoprostol is a stable, orally active synthetic analogue of prostaglandin E 1, available commercially for the treatment of peptic ulcer. Combined with mifepristone, it 137, 138 provides an effective, simple, inexpensive, completely oral or vaginal method. Although mifepristone does not induce labor, it does open and soften the cervix (this may be an action secondary to endogenous prostaglandins). The combined mifepristone-prostaglandin analogue method is usually restricted to pregnancies that are not beyond 9 weeks gestation. Other progesterone antagonists have been developed, but only mifepristone has undergone extensive abortion trials. It seems unlikely that mifepristone could have serious adverse effects, and there have been none reported. Mifepristone is most noted for its abortifacient activity and the political controversy surrounding it. As with mifepristone, a prostaglandin is added to promote expulsion of the uterine contents, and again vaginal misoprostol is the most useful analogue. The first trials demonstrated that if the prostaglandin (800 mg misoprostol vaginally) was given a week after the injectin of 145 methotrexate, this method could be almost as effective as mifepristone. Like mifepristone, efficacy diminishes with advancing gestation beyond 7 weeks (since the 146, 147 and148 last menstrual period). Because methotrexate takes longer to act than mifepristone, the prostaglandin is used a week after the initial treatment, and is repeated a day later if expulsion has not occurred. It has been used in low doses to treat psoriasis and rheumatoid arthritis, as well as ectopic pregnancy, without adverse effects. It is, however, a known teratogen that can be deadly in high doses, and its use as an abortifacient results in prolonged bleeding and a prolonged time to abortion (up to a month in some cases). The administration of tamoxifen (20 mg daily for 4 days) followed by misoprostol (800 mg vaginally, with a second dose if necessary 24 hours later) was associated with a 92% rate of complete abortion in 100 women with pregnancies less than 9 weeks 149 gestational age. Relatively high success rates have been reported with multiple dosing, but the most effective regimen and the best method of administration remain to be determined. Although the risk is low, this possibility must be considered in decision making when the various methods for first-trimester abortion are considered. Careful prospective follow-up assessments can detect no health differences in women who have medical abortions compared with women who have abortions by 155 vacuum aspiration. Complications of Abortions Postoperative complications of elective abortions are classified as either immediate or delayd. Delayed complications can occur several hours to several weeks after the operation. These usually present according to the major complaint: bleeding, pain, and continuing symptoms of pregnancy. Bleeding 114 By far the most common cause of unusually heavy postabortal bleeding is retained products of conception. Patients with retained products of conception occasionally present several weeks after an abortion, but most report excessive bleeding within one week. Treatment is prompt aspiration of the uterus with the largest cannula that will pass the cervix. Infection Infection is sometimes marked by uterine bleeding; although without retained products of conception, the volume of blood loss is usually modest. Fever and uterine 114 tenderness are the most common signs of postabortal endometritis, occurring in about 0. Some studies indicate that prophylactic antibiotics reduce the 156, 158 risk of postabortal infection. Most clinicians agree that women at risk of pelvic infection benefit from the use of prophylactic antibiotics prior to induced abortion; others state that women who have not had a previous delivery should receive prophylaxis, while still others believe that all abortion patients would benefit from 158, 159 prophylactic antibiotics. A meta-analysis of antibiotics at the time of induced abortion unequivocally concluded that prophylactic antibiotics should be routinely 160 used without exceptions. Because both gonorrhea and chlamydia, as well as other organisms, can cause postabortion infections, a tetracycline seems the best 161 drug for prophylaxis. Doxycycline, 100 mg an hour before the abortion and 200 mg 30 minutes afterward, is the most convenient and comprehensive regimen. Tetracycline, 500 mg once before and once after the operation, is also acceptable. Patients who present with uterine tenderness, fever, and bleeding require uterine aspiration as well as antibiotic treatment. Outpatient treatment with doxycycline, 100 mg bid for 14 days, should be reserved for patients whose signs and symptoms are confined to the uterus. Dysfunctional Uterine Bleeding Following Abortion Women may present with uterine bleeding but without signs or symptoms of retained products of conception or infection. When these two diagnoses have been ruled out by absence of fever, a closed cervix, and a nontender uterus, the bleeding itself can be treated hormonally. Ectopic Pregnancy Failure to diagnose ectopic pregnancy at the time of induced abortion can cause a patient to return with complaints of persistent bleeding with or without pelvic pain. Careful examination of the uterine aspirate for villi at the time of abortion should make a missed ectopic pregnancy an unusual cause of delayed bleeding. If, however, a patient presents with this possibility, quantitative measurement of chorionic gonadotropin and vaginal ultrasonography should be used for accurate diagnosis and management. Cervical Stenosis Patients who experience amenorrhea or hypomenorrhea and cyclic uterine pain after first-trimester abortion may have stenosis of the internal os. Possibly, the tip of this type of cannula abrades the internal os, and the minimal dilatation allows the abraded areas to heal in contact. The condition is easily treated with cervical dilatation with Pratt dilators under paracervical block. Approximately 4% of these women become sensitized following an induced abortion (the later the abortion the higher the proportion). Subsequent hemolytic disease of the newborn can be prevented by administering 50 mg Rh immunoglobulin to all Rh-negative, Du-negative women undergoing early abortion. Abortion in the Second-Trimester Second-trimester abortions can be accomplished surgically or medically. The D & E procedure is safer and less expensive than the medical methods and is better tolerated (and thus Abortion in the Second-Trimester Second-trimester abortions can be accomplished surgically or medically. These include the vaginal, intramuscular, or intra-amniotic administration of prostaglandins and the intra-amniotic injection of hypertonic saline or urea. The D & E procedure is safer and less expensive than the medical methods and is better tolerated (and thus 164, 165, 166 preferred) by patients. The training, experience, and skills of the surgeon are the primary factors that limit the gestational age at which abortion can be safely performed.

Anthropometric data from nutrition surveillance help to inform policy decisions medications definitions generic lamictal 50mg without a prescription, target and design programs and interventions medicine clip art buy 100mg lamictal amex, and identify and raise awareness about deteriorating nutrition situations before they reach crisis levels medicine clipart buy discount lamictal 100 mg online. Infuencing Policy and Strategy Development and Funding Levels Anthropometric data have been used widely to raise awareness and gain political support to improve the nutrition situation in countries symptoms 9 days after embryo transfer lamictal 100 mg on-line. Population-level anthropometric data can help governments medicine 2015 song buy lamictal amex, policymakers 8h9 treatment cheap lamictal 100 mg with visa, and donors understand and prioritize nutrition issues, identify vulnerable populations, design policies and strategies, and set aside funding to implement the policies and strategies. Based on these data, s/ he includes community-based management of acute malnutrition as part of the nutrition action plan to address the problem. Monitoring and Evaluation Anthropometric data are frequently used to monitor the implementation and measure the efectiveness of food security and nutrition interventions and programs. Anthropometry data are also used to compare the nutrition situation among countries and track nutrition-related global goals. The appropriate anthropometric measurement and index Common anthropometric to assess a given nutritional condition varies by condition and demographic indices include weight-for group. A growth reference describes how a Interpreting Anthropometric Data and Classifying specifc population has grown but does Nutritional Status for Individuals not necessarily refect optimal growth. However, while universally accepted international guidance exists for several of the measurements/indices and demographic groups in this guide. However, since they are not commonly used in international settings, they have not been included in this guide. There are two commonly used systems to interpret and classify 1 anthropometric data: z-scores and percentiles. Z-scores that fall outside of the normal range indicate a nutritional issue (undernutrition or overweight). Z-score cutofs are used to defne malnutrition according to anthropometric indices and measures. Z-scores can be estimated using growth charts/tables and/or calculated using computer software. For example, if 90 percent of children (grouped by age and sex) weigh less than 20 kg, then a child who weighs exactly 20 kg is in the 90th percentile for his/her age and sex (Gibson 2005). Normal stunting stunting May indicate Height-for-age endocrine Stunting a disorder. Birth weight measurements can refect that a child was born preterm, is small for gestational age, or both. The cutof below was selected based on an increased risk of obstetric complications. Anthropometric indicators are constructed from anthropometric measures or indices. An example of a population-level anthropometric indicator is: the percentage of children under 5 who are stunted (height-for-age < 2 z-scores). The new guidance can help identify populations at risk and can be used for targeting and planning interventions. The 2017 guidance updates the previous signifcance levels for stunting and wasting that were frst published in 1995, excludes underweight, and introduces thresholds for overweight. The approach to developing the 2017 thresholds was slightly diferent than that used in 1995. The 1995 wasting prevalence classifcations were based on increases in the crude mortality rate. The stunting and underweight thresholds were somewhat arbitrary groupings based on categorizing the prevalences in 79 low and middle-income countries into four levels (low, medium, high, very high) based on quartiles. The thresholds did not refect the relationship between the prevalences and population-level outcomes or note how far the prevalences deviated from normal. For example, consideration of the economy, climate conditions, food security trends, and migration in conjunction with anthropometry can help clarify the scope and magnitude of the situation. The tools and procedures will be adaptable to the country context relative to data systems in place, methodological approach to nutrition assessment, and policies and systems used to guide nutrition activities. Triceps Skinfold-for-Age and Subscapular Skinfold-for Age: Methods and Development. Management of Severe Acute Undernutrition: Consequences for Adult Health and Malnutrition in Infants and Children. In addition, nutritional defcits during this period can concepts that are relevant to all modules. When the child completes increased risks of noncommunicable disease, disability, and 60 months. Children in this age group, particularly under the age of 2, are very responsive to nutrition interventions, making this a critical period to act (Bhutta et al. Anthropometry is a key tool in the design and implementation of nutrition interventions seeking to address child malnutrition. It is helpful in determining and monitoring the nutritional status of individual children and the wider population, which provides information for the care and treatment of individuals, as well as for policy, program design, and resource allocation at the population level. This section provides a brief description of the most common nutrition-related conditions afecting children from birth to 5 years of age that can be identifed using anthropometry. The anthropometric measurements and indices used to identify these nutrition conditions are described in the Measurements section. Low birth weight Acute malnutrition Jump ahead to the Wasting Measurements Small head size/circumference section. Low birth weight can occur in infants who are born early (before 37 weeks of gestation), Gestational age refers to the length of are small for their gestational age and born at term, or are a pregnancy and is measured in weeks. Low birth weight is associated with increased weighs less than would be expected for risk of infant death, childhood stunting, and reduced brain a newborn of the same sex born from development in early childhood; children who are both small a pregnancy of the same length. A child for their gestational age and born early are at highest risk who is born early. Microcephaly may be present at birth (congenital) or develop after birth (acquired) and may result from genetic disorders, infections, exposure to drugs or chemicals, poor fetal growth, or severe malnutrition, among other reasons (U. While macrocephaly (large head size) is also of medical concern and can be identifed through anthropometry, it is not related to nutritional status and therefore is not discussed in this guide. Stunting often begins with poor growth in utero because of maternal undernutrition. The result is that the child is shorter than would be expected for a healthy child of his/her age and sex. Stunted children are more likely to die of infectious diseases such as diarrhea, pneumonia, and measles (Black et al. Stunting is also associated with poor cognitive and motor development and lower school achievement (Grantham McGregor et al. Children with acute malnutrition are at higher risk of death from infectious diseases (Black et al. A child with wasting has either moderate or severe acute malnutrition, depending on the severity of wasting. It may be caused by a child losing weight or not growing or not gaining weight at the expected pace and is often associated with illness and/or inadequate dietary intake. Overweight and obesity are complex conditions with multiple causes, including an imbalance between calories consumed and calories used, low levels of physical activity, medical conditions, and genetics, among others. Childhood overweight/obesity is associated with health risks in childhood and adulthood. This guide also measurements includes bilateral pitting edema, which is a clinical indicator, because it is frequently assessed and indices Height, measured while the child is standing, is used for children 24 months of age and older. In developing countries, it has traditionally been used at the population level for evaluation and benchmarking. However, If the age is unknown, children under 87 cm are recently, there have been eforts to use length/height-for measured lying down, and those 87 cm or taller are measured standing. Weight-for-age has been frequently used in growth promotion programs but has limitations because of its inability to distinguish between wasting and stunting. The age and sex-specifc interpretation is necessary because this age group is still growing and the relationship between weight, height, and fat changes based on stage of development and sex. Associated with brain volume, head circumference is afected by nutrition during pregnancy (in utero) and during the frst months of life (Bartholomeusz et al. Head circumference should frst be measured within the frst 24 hours of birth and continued until at least age 2 because this is the period of most rapid growth. Cases should be referred for further assessment and treatment, and a child with severe bilateral pitting edema requires inpatient care. Both standards provide information on how to classify anthropometric data based on two commonly used systems: z-scores and percentiles (see Box 2. For example, while a child in the 5th percentile would likely be identifed as having a growth problem, the equivalent z-score of 1. It demonstrates practices, health care, and in a healthy environment, regardless of ethnicity, how healthy children grow socioeconomic status, or location. The study specifcally selected children who were from healthy environments where recommended health behaviors were practiced A cutof is a threshold beyond which an individual is (including breastfeeding and standard pediatric care) and whose mothers did not determined to be malnourished.

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