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Continuous consumption of juice during the day increase during times in which dehydration is a risk. This amount is the total quantity for the whole day, including both time at early care Before a child enters an early care and education facility, and education and at home. Caregivers/teachers should the facility should obtain a written history that contains any not give the entire amount while a child is in their care. Food sensitivity includes a range of condi ship between the consumption of sweetened beverages tions in which a child exhibits an adverse reaction to a food and tooth decay. Drinks with high sugar content should be that, in some instances, can be life threatening. These written instructions must identify: Policy statement: the use and misuse of fruit juice in pediatrics. Regular to be substituted; sugarsweetened beverage consumption between meals increases f) Limitations of life activities; risk of overweight among preschoolaged children. Safe handling of raw should be used to develop individual feeding plans and, produce and freshsqueezed fruit and vegetable juices. A number of children Facilities should develop, at least one month in advance, with special health care needs have diffculty with feeding, written menus showing all foods to be served during that including delayed attainment of basic chewing, swallow month and should make the menus available to parents/ ing, and independent feeding skills. The facility should date and retain these menus utensils, and equipment, including furniture, may have to be for six months, unless the state regulatory agency requires adapted to meet the developmental and physical needs of a longer retention time. Some children have diffculty with slow weight gain and need their caloric intake monitored and supplemented. Some children have already been introduced (without any reaction), and are unable to tolerate certain foods because of their allergy then serve some of these foods to the child. In children, foods are considered for serving, caregivers/teachers should share are the most common cause of anaphylaxis. Nuts, seeds, and discuss these foods with the parents/guardians prior to eggs, soy, milk, and seafood are among the most common their introduction. Parents/guardians need to be low, as well as their designated roles during an emergency. If a child advance whether a child has food allergies, inborn errors of has diffculty with any food served at the facility, parents/ metabolism, diabetes, celiac disease, tongue thrust, or spe guardians can address this issue with appropriate staff cial health care needs related to feeding, such as requiring members. Some regulatory agencies require menus as a special feeding utensils or equipment, nasogastric or gastric part of the licensing and auditing process (2). Posting menus In some cases, dietary modifcations are based on religious in a prominent area and distributing them to parents/guard or cultural beliefs. Sample cial needs whether stemming from dietary, feeding equip menus and menu planning templates are available from ment, or cultural needs, is invaluable to the facility staff in most state health departments, the state extension service, meeting the nutritional needs of that child. Par the parents/guardians is essential for successful feeding, in ents/guardians may have to provide food on a temporary general, including when introducing ageappropriate solid or, even, a permanent basis, if the facility, after exploring all foods (complementary foods).

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In the analysis of hip fracture rates in Beijing and Hong Kong referred to above (102), it was noted that the rates in both cities were much lower than in the United States. The calcium paradox the paradox that hip fracture rates are higher in developed nations where calcium intake is high than in developing nations where calcium intake is low clearly calls for an explanation. Hegsted (103) was probably the first to note the close relation between calcium and protein intakes across the world (which is also true within nations [63]) and to hint at but dismiss the 166 Chapter 11: Calcium possibility that the adverse effect of protein might outweigh the positive effect of calcium on calcium balance. Only recently has fracture risk been shown to be a function of protein intake in American women (106). There is also suggestive evidence that hip fracture rates (as judged by mortality from falls in elderly people across the world) are a function of protein intake, national income, and latitude (107). The latter is particularly interesting in view of the strong evidence of vitamin D deficiency in hip fracture patients in the developed world (108114) and the successful prevention of such fractures with small doses of vitamin D and calcium (115, 116) (see Chapter 8). It is therefore possible that hip fracture rates may be related to protein intake, vitamin D status, or both and that either of these factors could explain the calcium paradox. We shall therefore consider how these and other nutrients (notably sodium) affect calcium requirement. Nutritional factors affecting calcium requirements the calculations of calcium requirements proposed above were based on data from developed countries (notably the United States and Norway) and can only be applied with any confidence to nations and populations with similar dietary cultures. Other dietary cultures may entail different calcium requirements and call for different recommendations. In particular, the removal or addition of any nutrient that affects calcium absorption or excretion must have an effect on calcium requirement. Two such nutrients are sodium and animal protein, both of which increase urinary calcium and must be presumed therefore to increase calcium requirement. A third candidate is vitamin D because of its role in calcium homeostasis and calcium absorption. Sodium It has been known at least since 1961 that urinary calcium is related to urinary sodium (117) and that sodium administration raises calcium excretion, presumably because sodium competes with calcium for reabsorption in the renal tubules. Regarding the quantitative relationships between the renal handling of sodium and calcium, the filtered load of sodium is about 100 times that of calcium (in molar terms) but the clearance of these two elements is similar at about 1 ml/min, which yields about 99 percent reabsorption and 1 percent excretion for both (118). However, these are approximations, which conceal the close dependence of urinary sodium on sodium intake and the weaker dependence of urinary calcium on calcium intake. It is an empirical fact that urinary sodium and calcium are significantly related in normal and hypercalciuric subjects on freely chosen diets (119122). The biological significance of this relationship is supported by the accelerated osteoporosis induced by feeding salt to rats on lowcalcium diets (123) and the effects of salt administration and salt restriction on markers of bone resorption in postmenopausal women (124, 125). Because salt restriction lowers urinary calcium, it is likely also to lower calcium requirement and, conversely, salt feeding is likely to increase calcium requirement. This is illustrated in ure 18, which shows that lowering sodium intake by 100 mmol (2. However, the implications of this on calcium requirement across the world cannot be computed because information about sodium intakes is available from very few countries (126). A metaanalysis of 16 studies in 154 adult humans on protein intakes up to 200 g found that 1. A small but more focussed study showed a rise of 40 mg in urinary calcium when dietary animal protein was raised from 40 to 80 g. This ratio of urinary calcium to dietary protein ratio (1mg to 1g) is a representative value, which we have adopted. This means that a 40g reduction in animal protein intake from 60 to 20 g (or from the developed to the developing world [Table 30]) would reduce calcium requirement by the same amount as a 2. ure 18 the effect of varying protein or sodium intake on theoretical calcium requirement.

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The required personnel, including nurses, anesthesia personnel, neonatal resuscitation team members, and obstetric attendants, should be in the hospital or readily available. Any hospital provid ing an obstetric service should have the capability of responding to an obstetric emergency. Historically, the consensus has been that hospitals should have the capability of beginning a cesarean delivery within 30 minutes of the deci sion to operate. The decisiontoincision interval should be based on the timing that best incorporates maternal and fetal risks and benefits. For instance many of these clinical scenarios will include highrisk conditions or pregnancy com plications (eg, morbid obesity, eclampsia, cardiopulmonary compromise, or hemorrhage), which may require maternal stabilization or additional surgical preparation before performance of emergent cesarean delivery. Conversely, examples of indications that may mandate more expeditious delivery include hemorrhage from placenta previa, abruptio placentae, prolapse of the umbili cal cord, and uterine rupture. Therefore, it is reasonable to tailor the time to delivery to local circumstances and logistics. Sterile materials and supplies needed for emergency cesarean delivery should be kept sealed but properly arranged so that the instrument table can be made ready at once for an obstet ric emergency. Inhouse obstetric and anesthesia coverage should be available in subspecialty care units. The anesthesia and pediatric staff responsible for covering the labor and delivery unit should be informed in advance when a complicated delivery is anticipated and upon admission of a patient with risk factors requiring a highacuity level of care. Intrapartum and Postpartum Care of the Mother 193 Before elective cesarean delivery, the maturity of the fetus should be estab lished. If any one criterion confirms gestational age assessment in a patient who has normal menstrual cycles and no immediate antecedent use of oral contraceptives, it is appropriate to schedule delivery at 39 weeks of gestation or later on the basis of menstrual dates. Cesarean delivery on maternal request is defined as a primary cesarean deliv ery at maternal request in the absence of any medical or obstetric indication. A potential benefit of cesarean delivery on maternal request is a decreased risk of hemorrhage for the mother. Potential risks of cesarean delivery on maternal request include a longer maternal hospital stay, an increased risk of respiratory problems for the baby, and greater complications in subsequent pregnancies, including uterine rupture and placental implantation problems. Cesarean deliv ery on maternal request should not be performed before a gestational age of 39 weeks has been determined, utilizing the most accurate gestational dating criteria available. Maternal request for cesarean delivery should not be moti vated by the unavailability of effective pain management. This form of delivery is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and the need for gravid hysterectomy increase with each cesarean delivery. In women undergoing scheduled cesarean delivery, whether primary or repeat, the presence of fetal heart tones should be confirmed and documented before the surgery. There is insufficient evidence to warrant further fetal moni toring before scheduled cesarean deliveries in lowrisk patients. However, in women requiring unscheduled cesarean delivery, fetal surveillance should con tinue until abdominal sterile preparation has begun. Antimicrobial prophylaxis is recommended for all cesarean deliveries, unless the patient is already receiving appropriate antibiotics (eg, for chorio amnionitis), and should be administered within 60 minutes of the start of the cesarean delivery. When this is not possible (eg, need for emergent delivery), prophylaxis should be administered as soon as possible. Given that cesarean delivery approximately doubles the risk of venous thromboembolism (although in the otherwise normal patient, the risk still remains low: approximately 1 per 1, 000), placement of pneumatic compression devices before cesarean delivery is recommended for all women not already receiving thromboprophylaxis. When the cesarean delivery is performed for fetal indications, consideration should be given to sending the placenta for pathologic evaluation. Pediatric and anesthesia personnel should be immediately available, as well as blood bank services.

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