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Theme 02

June 17, 2024

LESSON 2

Theme 1. Structure and function of children’s hospital and npaediatric department. Admission department of children’s hospital. nHospitalization, sanitization and transportation of sick children.

Theme 2. Organizatioof sanitary and epidemiological profile. Disinfection and sterilization of nchildcare devices. Personal hygiene of medical staff.

Theme 3. Technique of anthropometric measurements ichildren of all ages.

In Ukraine, there are some types of ntreatment and prophylactic institutions for children.

Pediatric ndepartment at a maternity hospital.

Pediatric npolyclinic is an institution for treatment and prophylaxis of children outside the hospital n(at home) before they turn 18 years old n(according to current data). The number of polyclinics depends on the npopulation of residential area (the bigger the city, the more polyclinics it nhas). A polyclinic may be incorporated with children’s hospital and may be aindependent institution.

The polyclinic is attached to a certaiterritory which is divided into ndistricts. Children nof each district are attended to by a district pediatrician ntogether with ndistrict nurses. One district should have not more tha800 children, not nmore than 60 children of one year of age, one pediatrician and one and na half (1,5) district nurses (for two pediatricians, and three nurses).

A principle document— “History of the nChild‘s nDevelopment”— is compiled by doctor and nurses for each child nfrom his/her birth till he/she turns eighteen years old. This document contains nall information about the child’s description of life and health condition. n”History of the Child’s Development” begins with a discharge note nfrom a maternity hospital. If a child arrives from other cities or villages, nhis parents are obliged to submit available history of development from the nplace of their previous residence to a polyclinic. When the child turns neighteen years old, the history of development is transferred to a polyclinic nwhich attends to adult patients.

“History of the Child’s nDevelopment” is drafted to ensure the continuity in the activities of nvarious structure of pediatricians working in the polyclinic: due to an exact nplan, various nspecialists consulte all children (e.g neurologist, surgeon, ndermatologist, ophthamologist, etc.).

Due to the work of all medical npersonnel, the following basic nfunctions of a polyclinic nare performed:

1. nMedical work:

(a) nMedical examination of nchildren performed by a district doctor and nsubject specialists in the building of the polyclinic (5 children per working nhour).

(b) nParents can call doctors, i.e. consultation by a ndistrict doctor at the homes of the children (one and a half nvisit per hour).

(c) nConclusion about treatment is made othe basis of check up. If necessity occurs, a child’s treatment can be ncarried out either under home conditions or the patient may be sent to a nchildren’s hospital: all data are put down into the “History nof the Child’s Development”; in case of hospitalization, all informatioabout treatment (‘Discharge form’) comes from a medical institution to a ndistrict doctor after discharge from hospital.

2. nThe purpose of prophylactic work nis prevention of possible diseases and disorders in the development of child:

(a) Precautions begin with the antenatal care, ni.e. with visiting a pregnant woman in domestic conditions; a healthy pregnant woman nis visited by the district nurse ntwice: the nfirst time (patronage) between the 20^th and 23^rd nweek of pregnancy, and for the nsecond time (patronage) between the 32^nd and 40^th nweek of pregnancy; doctor’s patronage (the third) is carried out by the ndoctor individually if any necessity occurs (abnormal pregnancy, diseases of a nwoman, poor living standards, etc.).

(b) Observation of nchild proceeds after birth:

§ During nfirst month of life — in-home observation.

§ During nfirst year of life — once a month.

§ nDuring second year of life — once per nquarter (quarter = 3 months), i.e. four times per year.

§ nDuring third year of life — twice a nyear.

§ nDuring 4-5 years of life — once a year.

§ nDuring sixth year of life— twice a year nthe child is examined by a district doctor and specialists in a polyclinic. nDecisions about physical, psychological, intellectual and other parameters of nthe child’s development are made on the basis of these examinations. If nnecessary, different methods of examination are prescribed; special nconversation with mother is carried out, etc. Thus, the “History of nChild’s Development” contains all information about state of health of ngrowing generation.

3. Anti-epidemical work nis a complex of actions aimed at timely diagnosis and prophylaxis of infectious ndiseases. Basic moments of nanti-epidemical work are:

(a) nVaccination.

(b) nObservation of vaccinated children, nespecially if post-vaccination complications (allergic reaction, etc.) are npresent.

Children’s hospitals nfor children till 18-years of age are divided into:

(a) nAccording to the territory they serve:

• nMunicipal.

• nDistrict.

• nRegional.

• nNational.

(b) nAccording to the variety of departments:

• nMulti-departmental n(one hospital contains departments of different specialization, i.e. nprematurely born department, cardiology department, surgery department, etc.; nthese are usually regional children’s hospitals).

• nSpecialized n(children with one group of particular diseases are cured there, e.g. hospitals nfor curing infectious diseases, etc.).

§ nIncorporated with a polyclinic.

§ nWithout a polyclinic.

(d) nAccording to the volume of work (it ndepends on a number of beds, i.e. a maximum number of patients that can be nproperly served in a department at the same time.

(e) nClinic is a hospital where not only nmedical treatment but also research work and training of students, are carried nout.

Usually one doctor-pediatrician cures 20 nchildren. In serious and severe cases (for example, in regional hospital, ireanimation department=intensive care unit) the pediatrician cures from 5 to 10 nchildren.

In children’s hospital whose main function is medical nwork, responsibilities of medical personnels include the nfollowing stages:

– nTo accept patient and if necessary, to nrender the urgent help.

– nTo prescribe all necessary analysis and nexaminations.

– nTo diagnose correctly and quickly.

– nTo carry out all complex of medical nmeasures.

– nTo strengthen the immunity of the child nagainst repeated diseases or possible relapse of chronic pathology.

– nOn the day of discharge, to prepare a n”Discharge form’.

Dispensary is an institution for ntreatment and prophylaxis where children with a certain group of diseases n(for example, antituberculous, endocrinopathic) are examined, constantly nobserved and treated if necessary.

Children’s health centre is ainstitution for treatment and prophylaxis that are located in appropriate nresort zones (in Ukraine it is Crimea, Carpathian Mountains, etc.). Sick nchildren are sent there for the period of 1-3 months or longer if necessary. nThe children are cured there by specific methods. For example:

(a) nClimate therapy — a child stays under nconditions of seaside climate (it stimulates organism, improves characteristics nof blood and raises appetite).

(b) nThalassotherapy —treatment by sea water nwhich is effective if there is delay of physical development, diseases of skin, nnervous system, respiratory tracts.

(d) nEstuary cure — it is very effective idiseases of metabolism, nervous system, rheumatic fever and polyarthritis.

(e) nSand baths — is similar to mud cure.

(f) nBalneotherapy— is using medical mineral nwaters that promote treatment of cardiovascular, nervous, urinary and other nsystems depending on its contents.

Institutions that also render treatment nand prophylaxis, mainly preventive, include:

(a) nKindergarten n(in Ukraine) are attended by children from 3 to 6-7 years, when parents are at nwork.

(b) nOrphanage home (= nchildren’s home) is an institution for nthe children of preschool age (from the first month of life) who for different nreasons caot live with their parents (e.g. parents are mentally retarded, nparents died, children were abandoned, etc.).

Basic statistical data nof activity of children’s treatment and prophylactic institutions are:

nNumber of children born alive during one year x 1000

Level of birth rate = ——————————————————- ————

n Average annual population

Mortality nrate nNumber of children dead during the first year of life in a givex 1000

= ————————————————————————————–

(number nof children’s death 2/3 born alive in the ngiven year + 1/3 born alive in the previous year

during nthe first year of life)

Infant mortality in our country ranges nfrom about n10-15 %o (%o = per mille — a unit of measurement equal to n1/1000 of 100% = 1/10 of 1%). nIn n1995, this figure was 14.7 %₀. nDuring the past n10 years, these parameters have fluctuated and in 2008, nit was n10.36 %o.

However, the infant death rate iUkraine is approximately 15 times lesser than any other country of CIS; but, nunfortunately, it is 2-7 times more than in countries of European Union.

Death rate of children nNumber of children dead at the age of 0 to 14 years during the given year

aged from 0 to 14 years n= —————————————————————————————- nx 1000

nAverage children’s population younger than 14 years

n General number of diseases registered first time in one year x 1000

Morbidity rate n= n———————————————————————————

Average nannual children’s population

Quality of diagnostics nat Number of diagnosis at the directionot coinciding with clinical diagnosis x 100

prehospitalizatiostage = ——————————————————— —————————————–

n Number nof patients discharged from the or nother doctor of polyclinic hospital

Concept nabout health of children

For estimation of the nhealth of children till 3 years of age, 5 criteria are established:

(a) nCondition of physical development.

(b) nCondition of psychomotor development.

(d) nFunctional condition nof the main systems. (Respiratory, Cardiovascular, nUrinary, etc.)

(e) nThe degree of nresistibility and reactance of an organism— ni.e. how the child endures possible viral and bacterial diseases (e.g. ninfluenza, bronchitis, etc).

Medical report defined the term ‘health’ nas a condition where results of all necessary medical examinations have provethe absence of diseases and traumas. However, we should take note that n”health” — is (a) state of complete physical, mental and social nwell-being and not merely the absence of disease or infirmity” (WHO).

According to current data, some childreunder 3 years especially due to their social factors can be highlighted by npediatricians into the so-called nrisk group. These are children from families who find themselves nin difficult circumstances (adverse moral and material living conditions).

WORK nIN THE CHILDREN’S HOSPITAL

Reception

The child directed to a hospital gets ninto a reception room where his initial examination will be carried out.

The appointment card (= direction letter n= referral note) may be given by the polyclinic doctor, the specialist, or the nfamily doctor; the patient may be delivered by the ambulance. Only patients isevere condition can be accepted without an appointment card.

In an appointment card, the full name, nage, permanent address, preliminary diagnosis, if possible — the data of the ncarried out inspection, and also date, surname of the doctor and a medical seal nor a seal of the establishment are given. Besides, with the purpose of preventive ncare of an infectious disease in the non-infectious hospital, the ninformation about the child’s contact with infectious patients is necessary nto be indicated in the appointment card, as well as possible infringements of nstool (‘yes’ or ‘no’, if ‘yes'”— then we should find when there was a ncontact with an infected person, as each infectious disease has its owincubation period — this is known by the doctor). At the presence of contact of na patient with a child with infectious diseases (in case of obligatory nhospitalization) He/She will be admitted in the special isolation ward or will nbe transferred to the infectious department.

City children’s hospital # 3 Appointment card

Borody Oleg lv., 2 years old, the address is: Solnitchnaya str., 14/92, goes o hospitalization.

The diagnosis: Acute Bronchitis.

Iron deficient anemia of 1st degree.

The general blood analysis on 14.12.2010: RBC — 3.4 T/L, Hb — 92 g/L, WBC — 10 G/L, ESR — 12 mm/hour.

No contact with infectious patients, infringements of stool are not present.

15.12.2010 Sign, and stamp of local doctor

If the child is delivered into the ndepartment without nparents (in cases of accident, trauma, sudden significant ndeterioration of the health state), the information of hospitalization should nurgently be told to the parents of the patient or the local police statioshould be informed for the search of the parents in case the child’s health is ndeteriorated.

In children’s medical establishment, nthere is an independent reception with separate medical personnels (doctors, nnurses). In small children’s hospitals, the child is accepted by the doctors oduty in the children’s branch or the pediatricians occupying the post of the ndoctor on duty in the hospital, sometimes local doctors do it.

Receptioof the patient should be carried out according to the following standard nobligatory plan

1. nRegistration n— First the nurse fills in the data concerning the patient in the ‘Admissioregister’ or ‘hospitalization register’, (date, full name, age of the child, nthe address, the diagnosis in the appointment card) and draws up a passport npart in the case history.

Simultaneously, the child’s body ntemperature is measured and later examined by the doctor on duty. The specified norder is broken in case when a condition of the patient is severe nand demands urgent help.

2. nDoctor’s examination n(collection of complaints, the anamnesis of diseases and life, the estimatioof the child’s condition, etc.) is carried out in approximately 20-30 minutes ndepending on the disease and seriousness of the condition of the child. Thethe doctor (in our country personally) nwrites down all received data in the case history. At the end of this, the npreliminary diagnosis, a plan of the inspection of the patient and his ntreatment are indicated (the list of medications and medical procedures).

3. nAfter examination by the doctor and the ncase history is filled, the nurse carryies out the sanitary processing of the npatient:

First of all, the hygienic condition of nthe child (by examination of the neck, ears and all surface of the skin, nails non the fingers and toes, as well as the hair) is checked.

In case of long nails, they should be ncut.

At diagnosis of pediculosis, the nappropriate processing should be carried out.

Then, if necessary, naccording to the prescription of the doctor, the child takes a hygienic bath or nshower.

Attention! nIn case of nsevere condition of the patient, sanitary processing should be carried nout only after rendering the urgent help and with the permission of the doctor.

4. nAfter reception, the child is transferred nto an appropriate department. The kind of transportation is defined by the ndoctor depending on the condition of the patient:

• nIf the state of health of the child is nsatisfactory, then he/she can go to the department independently under nthe nurse’s supervision.

• Childreof the first-second year of life are carried on hands.

• nThe medical staff transports heavy npatients ostretcher, carriages , etc.

• nIn absence of carriages, lift escalator nor elevetor, the child of an advanced age can be transferred on the bed sheets or blanket.

Transportation of the patient comes to nan end with the ncase history and the prescription form (the plan of treatment and ninspection of the patient):

To na nurse from the child’s department (if a ncondition of the patient is not severe, in evening-night shift).

To the doctor on duty n(in the afternoon; if the condition of the patient is very serious at any time nof the day).

If the child is under 1 year of age, feeding schedule nis also prescribed. Besides, an additional verbal communication with the ndepartment about the condition of the hospitalised patient is necessary.

Simultaneously we shall consider kinds nof possible transportatioof the patient outside the hospital (Attention! nIt may be only if the condition of the patient allows transport him/her):

• By ambulance.

• Sanitary aircraft— nby plane, helicopter (in mountainous place, for urgent transportation to far ndistances).

• In emergency cases n— any road ntransport.

Except the specified function of a nreception room n(reception of patients and their hospitalization), it has one nmore function — nthe registration of the movement of patients in a medical establishment. nWith this purpose, the medical staff fills the following documents:

(a) nHospitalization register.

(b) nIn case parents refuse hospitalization, nthe data on the patient are written down in special refusal register; nbesides, at refusal, in some cases (such as infectious disease and severe ncondition of the child), the doctor in the reception must inform the local ndoctor and the school where the child studies (the kindergarten) about the nsituation.

(d) nRegister nof transferring to other hospitals. nFor example: nafter significant deterioration of the condition, the patient from the small ncity hospital is transferred to reanimation department (= department of nintensive therapy = Intensive Care Unit — ICU) of the regional children’s nhospital, the child from cardiological branch is transferred

to surgical nbranch in connection with the development of acute appendicitis, etc. (e) Register of fatal cases.

It is clear that the list of patients ithe 1^st journal should be equal to the total amount of patients ithe last three registers.

Medical ndepartment

During all the time of stay in a nhospital, the child is treated in the medical department. In total, the nhospital may have from 1 -2 up to 10 and more departments depending on its nsize. In one children’s department, there may be patients with different nuncontageous diseases (rheumatic fever, pyelonephritis, gastritis; in the same nbranch, only in a separate chamber, patients with bronchitis, pneumonia, etc.). nThere are specialized hospitals in which children with diseases of one system n(cardiological, gastroenterological, hematological, etc.) are treated.

The nmain objective of all medical personnel in the department nis an operative inspection of the patient, the timely statement of the correct ndiagnosis and, at an opportunity, the full treatment of the child or (in case nof incurable disease) realization of the necessary complex of medical actions nfor the patient.

Structure nof the children’s department

The department consists of isolated ward n(= chamber = room — in some countries) sections; for children of the 1^st nyear of life, there should be no more than 24 beds, over one year— not more nthan 30 beds. In one ward there may be accordingly 1-4 and 4-6 beds. The best nfor the children of breast-feeding age are box wards, when every child has his nown ward which prevents possible infections to other patients. Till this time, nin some hospitals, according to the old rule there are wards which may not be nvery effective half-boxes with wooden- glass partitions only between beds.

Hygienic nrequirements in wards are:

· nThe distance between beds should not be nless than 1.5 m.

· nEvery child should have a personal nbedside table and a case for clothes.

· nIn each ward, one quartz lamp should be nhung.

· nIf there is no separate toilet near the nward, then the presence of a washbasin with cold and hot water is necessary.

Generally, the structure nof the nchildren’s department comprises of:

· nThe department manager’s nroom.

· nDuty room n— a room for the doctors work.

· nA room of the senior nnurse.

· nA post of the attendant nnurse (on duty); for the convenience nof constant supervision, it is often located in corridors of the department; nnear the table of the nurse, there are some hospital shelves in which the most nnecessary medicines and medical tools are kept.

· nIn the department, there is nurse’s room nfor inter-muscular injections, eye dropping and other medical procedures, iwhich, by obligatory rules, medical products and tools for manipulations are nkept in the safe, refrigerator or in usual shelves.

· nA separate (!) manipulatioroom for intravenous injections.

· nIn the branch, usually there is a nspecial separate room for specific medical nprocedures with the purpose of treatment and inspection n(for example, for intubation of the patient, examination by the ENT-doctor, the nurologist, and the gynecologist, etc.).

· nA physical nprocedure cabinet (inhalation, nelectrophoresis, etc.).

· nA dining room.

· nA rest room for the ndoctor on duty.

· nBathhroom.

· nA toilet n(separate for medical staff and patients).

Theme 2. nOrganizatioof sanitary and epidemiological profile. Disinfection and sterilization of nchildcare devices. Personal hygiene of medical staff.

Sanitary-and-hygienic nand anti epidemic regime is the extensive complex of actions which are carried nout by all employees of the medical personnel, and also by patients, the npurpose of it is maintaining cleanliness nin the medical establishment and anticipation of future epidemics of infectious ndiseases.

The following rules are included into nthe structure of these actions.

As it was mentioned above, in an appointment ncard, the doctor should specify the data of the contact of the nchild with infectious patients.

Despite of the anamnesis written in the nrefferal form, a doctor at a hospital to which the patient is reffered, has to nenquire on nthe epidemiological anamnesis once more (see pg. 80). As for the ntactics of the doctor in case of the positive anamnesis you, students, already nknow it. Even if the epidemiological anamnesis of the child is not aggravated, nthe patient needs to be examined carefully in a reception to avoid ainfectious pathology.

Sanitary procedures nwhich should be primarily carried out at reception lasts during all the time of nstay of the patient in a hospital. If mother is in a hospital, then once a nweek, she will cary out the procedures in place of a nurse. Every week each npatient takes na hygienic bath.

In the department, bed sheets and clothes nshould be changed in due time. The frequency of the change depends on the npathology, age of the child and his condition.

Furniture and the object of common use (couch and pillow non it) should nbe covered with polyethylene film which is wiped up by 1% sol. of nchloramines or 0.5% sol. of chloride of lime 2 times after every patient, with nan interval of 15 minutes, and after that with water. Sterile disposable film nsheets can be used. Simultaneously after every patient, the bed sheet on a ncouch are changed.

The medical staff should observe the rules of npreparation and distribution of food, and npatients — nrules of eating food. Usually, it is prepared in a special room. nAfter delivery to the department, it is possible to keep food stuffs in a separate room nnot longer than 2 hours. Portions are given into a dining room nthrough a special window. The utensils are exposed to special processing nafter use.

There should be drinking water for npatients.

All nworkers of the department are obliged to observe the rules of personal hygiene, as well as nevery patient is obliged to carry out nall rules of personal hygiene.

One of the main anti-epidemic actions is disinfection nwhich helps to prevent nthe distributions nof microbes of illnesses in the hospital and their destruction.

The disinfection can be:

a. nPreventive.

b. nCarried out in the epidemic center which nis divided into:

· nCurrent.

· nFinal.

Preventive disinfection nis a complex nof actions for preventing the accumulation and distributions of nactivators of diseases in the hospital. Preventive disinfectioshould be carried out by the following ways:

1. nVentilatioof wards — nfour times a day.

2. Quartz n(UVR) wards 2 times a day for 15 minutes.

3. Vacuum cleaning or shaking nout in the fresh air of soft things (e.g. mattresses, blankets, curtains, netc.).

4. The ncomplex of preventive disinfection includes the above mentioned i nules of the nobservance of hygiene by medical staff and patients, and also the rules of preparing nand distribution of food.

5. Wiping at least 2 times a day n(in some departments — more often, for example, in the infectious one — 4 times na day) the nfloor, windows, furniture. toys with specially nprepared solutions, for example:

(a) Chloride of lime (now rarely used) — fine powder of nwhite color; it is necessary to keep it in the dry pack protected from the nlight; only the patient’s excrements nare disinfected with this dry powder. nChloride of lime in the liquid form nis made and applied as follows:

· nAt the beginning, a nspecial 10% or 20% solution nis prepared (so-called ‘clarified’): nthe necessary quantity of the dry powder (for example, 1 kg to 10 L of 10% solution) is stirred in a small amount of water; then gradually; water is added up to the necessary volume (in this case — up to 10 L) and at constant stirring, till the formation of homogeneous mix is achieved. The nreceived structure is covered with a lid.

· nApproximately in 1 hour, the mix is nmixed up once more, in 1 hour— once again, and after 1 hour — once again; thus, nwithin the first 3 hours it is mixed up 3 more times.

· nIn 24 hours, from the beginning of nmanufacturing, the ready clarified solution (in this case 10%) is poured out nand then kept for no more than 7 ndays in enameled, wooden, metal (protected nfrom corrosion) well-closed basin.

Examples nof calculation of the quantity:

~ 500 g of powder and water up to 5 L = 5 L of the 10% solution

~ n2 kg of powder and water up to 10 L = 10 L of the 20% solution

· nAt work, nthe so-called working solution nis used 0.5-1%, which is made

§ nby the necessary dilution of the nclarified solution. Examples of calculation:

~ 1 L of the 10% main solution + 9 L of water = 10 L of the 1% working solution

~ 1 L of the 20% main solution + 19 L of water = 20 L of the 1% working solution

~ 500 ml of the n10% clarified solution + water (up to 10 L) = 10 L of the 0.5% working solution

· nThe working solution can be used no more than 24 hours.

· nFor cleaning windows, the floor, nfurniture, toys, etc. n0.5% solution of chloride of lime nis used.

(b) Chloramines В n(in dry form, it is a powder of white color) — for usage,

1% solution is made by ngradual stirring of the necessary quantity of the powder, first in a small nvolume of hot water (50-60°C), and then adding more and more water up to the necessary full volume (for example: 50 g of powder and 5 L of water). To store a solution is possible no more than 5 ndays.

(c) Dezaktin— ndry powder mixed in water for 1-2 minutes, for the formation of 0.1-2.5% nsolution which is used for the current and final disinfection. When water ntemperature is 60°C, there will be an accelerated dissolution of the medium (for concentrations over 0.5%). You can nsave 24 hours.

The current disinfection is a complex of actions for the reduction of ninfection in the whole room near the centre of the infection. nFor example: nin the child’s department (non-infectious) on the 1^st floor of ward n#4, a child who is hospitalized for the treatment of pneumonia, suffers from nsalmonellosis as well; the current disinfection should be carried out on the nterritory of the whole 1^st floor.

Three kinds of ndisinfection are applied:

1. nChemical n— for disinfecting toys, furniture, windows, the floor etc. with disinfectant nsolutions of high concentration — 1% solution of chloride of lime and 2% nsolution of Chioramines.

2. nPhysical n— boiling subjects (pans, dishes, etc.) in water; the addition of soda or some nlaundry soap (10-20 g in 1 L of water) is effective.

3. nMechanical— nwashing the linen, removal of dust and dirt with a damp duster.

The final disinfection is an utter nelimination of the activator of a disease in the centre of the infection (according to the ngiven example, in ward # 4 it

is necessary to carry nout not current, but final disinfection). nThus, the above mentioned concentrated liquid disinfectant solutions, dry npowder are used. Many subjects (footwear, books) are processed in disinfectiowards.

Pediculosis

CLINICAL MANIFESTATIONS

Ø nItching is the most common symptomof nhead lice infestation, but many children are asymptomatic.

Ø nAdult lice or eggs (nits) are found ithe hair, usually behindthe ears and near the nape of the neck.

Ø n Excoriations and crustingcaused nby secondary bacterial infection may occur and oftenare associated nwith regional lymphadenopathy.

Ø nIn temperate climates,head nlice deposit their eggs on a hair shaft 3 to 4 mm fromthe scalp. Because hair grows at a rate of approximately 1 cmper month, the duration of infestation can be estimated by thedistance of nthe nit from the scalp.

The technique of eliminating nprocess of the child at revealing head lice:

q nIt is possible to shear hair (it is nusually done with boys — an ideal momentary way!) or to process the nhead of the patient with one of solutions used for such a purpose: Lotions n’Nittifor’, ‘Miloca’, ‘Lanchet’, special shampoos, etc.

q nAfter processing, the head is nwrapped up with a polyethylene bag, then a scarf is put on it; isuch position, the child stays for 20-40 minutes (according to the ninstruction).

q nThen, the head is washed by nhot water with laundry soap.

q nThe next moment is the most scrupulous none; it is gradual combing of the patient’s hair with a nfine-tooth comb with a piece of cotton wool (moistened in 9% vinegar solution).

q nThe head is swilled with a lot of water.

Cut off hair, and the hairs cut should nbe put on an oilcloth and burnt. At revealing only nits, it is possible nto apply more simple solution: the hair is processed with warm (30°C) 9% solution of vinegar, then for 15-20 minutes, the head is wrapped up with a scarf, after nthat, the hair is combed out and the head is washed.

The clothes on which body lice nare revealed should be packed into a polyethylene bag and sent into the chamber nfor disinfection.

Scabies

CLINICAL MANIFESTATIONS n

nScabies is characterized by an intenselyⁿpruritic, erythematous, papular eruption caused by burrowingof nadult female mites in upper layers of the epidermis, creatingserpiginous nburrows.

nItching is most intense at night.

nIn olderchildren and adults, nthe sites of predilection are interdigitalfolds, flexor aspects of nwrists, extensor surfaces of elbows,anterior axillary folds, nwaistline, thighs, navel, genitalia,areolae, abdomen, intergluteal ncleft, and buttocks. In childrenyounger than 2 years of age, the neruption generally is vesicularand often occurs in areas usually nspared in older children andadults, such as the head, neck, palms, nand soles . The eruptionis caused by a hypersensitivity reaction to nthe proteins ofthe parasite.

nThe characteristic scabietic burrows nappear as gray or white,tortuous, thread-like lines. Excoriations nare common, and mostburrows are obliterated by scratching before a npatient is seenby a physician. Occasionally, 2- to 5-mm red-brownodules arepresent, particularly on covered parts of the body, such nasthe genitalia, groin, and axilla. These scabies nodules area ngranulomatous response to dead mite antigens and feces; thenodules ncan persist for weeks and even months after effectivetreatment.

nCutaneous secondary bacterial infectiocan occurand usually is caused by Streptococcus pyogenes or Staphylococcusⁿaureus

TREATMENT

q nInfested children and adults should napply lotionor cream containing a scabicide over their entire body nbelowthe head. Because scabies can affect the head, scalp, and neckⁿin infants and young children, treatment of the entire head,neck, nand body in this age group is required.

q nThe drug of choice,particularly nfor infants, young children, and pregnant or nursingwomen, is 5% npermethrin cream (not approved for children youngerthan 2 months of nage), a synthetic pyrethroid. Alternative drugsare 10% crotamiton, nivermectin, or 1% lindane cream or lotion.Permethrin should be nremoved by bathing after 8 to 14 hours.

q nCrotamiton is applied once a day for 2 ndays followed by a cleansingbath 48 hours after the last napplication, but crotamiton isassociated with frequent treatment nfailures and has not beenapproved for use in children. n

Pinworm Infection/Enterobius vermicularis

CLINICAL MANIFESTATIONS n

Ø nAlthough some people are asymptomatic, npinworm infection (enterobiasis) may cause pruritus ani and, rarely, pruritus nvulvae.

Ø nPinworms have been found in the lumen of nthe appendix, but most evidence indicates that they are not related causally to nacute appendicitis.

Ø nMany clinical findings, such as grinding nof the teeth at night, weight loss, and enuresis, have been attributed to npinworm infections, but proof of a causal relationship has not beeestablished.

Ø nUrethritis, vaginitis, salpingitis, or npelvic peritonitis may occur from aberrant migration of an adult worm from the nperineum.

TREATMENT n

q nThe drugs of choice are mebendazole, npyrantel pamoate, and albendazole, all of which are given in a single dose and nrepeated in 2 weeks.

q nPyrantel pamoate is available without nprescription.

q nFor children younger than 2 years of nage, in whom experience with these drugs is limited, risks and benefits should nbe considered before drug administration. Reinfection with pinworms occurs neasily; prevention should be discussed when treatment is given.

q nInfected people should bathe in the nmorning; bathing removes a large proportion of eggs. Frequently changing the ninfected person’s underclothes, bedclothes, and bedsheets may decrease the egg ncontamination of the local environment and decrease risk of reinfection. nSpecific personal hygiene measures (egg, exercising hand hygiene before eating nor preparing food, keeping fingernails short, avoiding scratching of the nperianal region, and avoiding nail biting) may decrease risk of autoinfectioand continued transmission. Repeated infections should be treated by the same nmethod as the first infection.

q nAll family members should be treated as na group in situations in which multiple or repeated symptomatic infections noccur. Vaginitis is self-limited and does not require separate treatment.

Ascaris lumbricoides Infections

CLINICAL nMANIFESTATIONS

Ø Most ninfections are asymptomatic.

Ø Moderate nto heavy infections may lead to malnutrition, and nonspecific gastrointestinal ntract symptoms may occur in some patients.

Ø During nthe larval migratory phase, an acute transient pneumonitis associated with nfever and marked eosinophilia may occur.

Ø Acute nintestinal obstruction may develop in patients with heavy infections. Childreare prone to this complication because of the small diameter of the intestinal nlumen and heavy worm burden.

Ø Worm nmigration can cause peritonitis, secondary to intestinal wall penetration, and ncommon bile duct obstruction resulting in biliary colic, cholangitis, or npancreatitis.

Ø Adult nworms can be stimulated to migrate by stressful conditions (eg, fever, illness, nor anesthesia) and by some anthelmintic drugs.

Ø Ascaris nlumbricoides has been found in the appendiceal lumen in patients with acute nappendicitis, but a causal relationship is uncertain.

TREATMENT n

nAlbendazole in a single dose, nmebendazole for 3 days, or ivermectin in a single dose is recommended for ntreatment of asymptomatic and symptomatic infections. Although limited data nsuggest that these drugs are safe in children younger than 2 years of age, the nrisks and benefits of therapy should be considered before administration.

nReexamination of stool specimens 3 weeks nafter therapy to determine whether the worms have been eliminated is helpful nfor assessing therapy but is not essential.

nSurgical intervention occasionally is nnecessary to relieve intestinal or biliary tract obstruction or for volvulus or nperitonitis secondary to perforation. If surgery is performed for intestinal nobstruction, massaging the bowel to eliminate the obstruction is preferable to nincision into the intestine. Endoscopic retrograde cholangiopancreatography has nbeen used successfully for extraction of worms from the biliary tree.

The following rules are included into nthe structure of these actions.

As it was mentioned above, in an appointment ncard, the doctor should specify the data of the contact of the nchild with infectious patients.

In the department, bed sheets and clothes nshould be changed in due time. The frequency of the change depends on the npathology, age of the child and his condition.

There should be drinking water for npatients.

All nworkers of the department are obliged to observe the rules of personal hygiene, as well as nevery patient is obliged to carry out nall rules of personal hygiene.

One of the main anti-epidemic actions is disinfection nwhich helps to prevent nthe distributions nof microbes of illnesses in the hospital and their destruction.

The disinfection can be:

c. nPreventive.

d. nCarried out in the epidemic center which nis divided into:

· nCurrent.

· nFinal.

1. nVentilatioof wards — nfour times a day.

6. Quartz n(UVR) wards 2 times a day for 15 minutes.

7. Vacuum cleaning or shaking nout in the fresh air of soft things (e.g. mattresses, blankets, curtains, netc.).

8. The ncomplex of preventive disinfection includes the above mentioned i nules of the nobservance of hygiene by medical staff and patients, and also the rules of preparing nand distribution of food.

9. Wiping at least 2 times a day n(in some departments — more often, for example, in the infectious one — 4 times na day) the nfloor, windows, furniture. toys with specially nprepared solutions, for example:

· nApproximately in 1 hour, the mix is nmixed up once more, in 1 hour— once again, and after 1 hour — once again; thus, nwithin the first 3 hours it is mixed up 3 more times.

Examples nof calculation of the quantity:

~ 500 g of powder and water up to 5 L = 5 L of the 10% solution

~ n2 kg of powder and water up to 10 L = 10 L of the 20% solution

· nAt work, nthe so-called working solution nis used 0.5-1%, which is made

§ nby the necessary dilution of the nclarified solution. Examples of calculation:

~ 1 L of the 10% main solution + 9 L of water = 10 L of the 1% working solution

~ 1 L of the 20% main solution + 19 L of water = 20 L of the 1% working solution

~ 500 ml of the n10% clarified solution + water (up to 10 L) = 10 L of the 0.5% working solution

· nThe working solution can be used no more than 24 hours.

· nFor cleaning windows, the floor, nfurniture, toys, etc. n0.5% solution of chloride of lime nis used.

(d) Chloramines В n(in dry form, it is a powder of white color) — for usage,

(e) Dezaktin— ndry powder mixed in water for 1-2 minutes, for the formation of 0.1-2.5% nsolution which is used for the current and final disinfection. When water ntemperature is 60°C, there will be an accelerated dissolution of the medium (for concentrations over 0.5%). You can nsave 24 hours.

Three kinds of ndisinfection are applied:

1. nChemical n— for disinfecting toys, furniture, windows, the floor etc. with disinfectant nsolutions of high concentration — 1% solution of chloride of lime and 2% nsolution of Chioramines.

2. nPhysical n— boiling subjects (pans, dishes, etc.) in water; the addition of soda or some nlaundry soap (10-20 g in 1 L of water) is effective.

3. nMechanical— nwashing the linen, removal of dust and dirt with a damp duster.

The final disinfection is an utter nelimination of the activator of a disease in the centre of the infection (according to the ngiven example, in ward # 4 it is necessary to carry out not ncurrent, but final disinfection). Thus, the above mentioned nconcentrated liquid disinfectant solutions, dry powder are used. Many subjects n(footwear, books) are processed in disinfection wards.

Special features of the nmedical personnel hygiene

Dear students, surely nyou know all the rules of personal hygiene of the medical personnel, therefore nthey are only listed here: 9 Tidy appearance.

• nA standard medical smock (coat).

• nA cap or a kerchief on a head.

• nShort nails.

• nSpecial hospital footwear which is neasily disinfected (for example, leather).

• nHands well washed up with soap.

• nTo medical sisters and doctors engaged nin surgical manipulations, watches, rings, varnish oails are forbidden.

• nAccording to indications (the maternity, ninfectious department, epidemic of influenza, etc.) a mask is put on; it is nnecessary to change a gauze mask every 4 hours; at an opportunity, it is better nto use disposable sterile masks.

The nbasic duties of a junior medical personnel:

• nDamp cleaning in the medical institutio(they should know the frequency of cleaning and contents of the liquid used idifferent rooms).

• nSupervision of sanitary conditions of nfurniture in the ward, corridor, etc.

• nSanitary processing of the patients, nbeginning with the reception.

• nHelping the child in observing the rules nof personal hygiene (combing hair, trimming nails, etc.).

• nChanging bed covers, bed sheets and npatients’ clothes.

• nPrevention of bedsores.

• nNecessary medical aid to a serious npatient in micturition, defecation (for example, to keep a bedpan).

• nHelping the nurse in some methods of ninspection (collecting urine, stool; measuring of weight and height of the nchild, etc.).

Work nof the doctor-pediatrician in a hospital

In every children’s department, there is na managing branch and attending physicians.

The basic duties nof a doctor-pediatrician of the children’s department include:

• Admissioof the patients (in case of the nabsence of a separate admitting room).

• Daily nobservatioof the patients.

• Daily nfilling up nof the case history.

• Daily nviewing and nadditional filling of the list of medicines to be given).

• Consultations with the patient’s parents nat their request during the whole time of hospitalization, especially during ndischarge from the hospital (the explanation of the child’s condition, nacquaintance with the results of inspections, advice, and recommendations).

• Ithe morning, obligatory presence at the briefing of medical personnels of nthe department.

• Simultaneously nwith the nurse — carrying nout of some difficult manipulations (such as blood transfusion; nintravenous introduction of plasma, contrast substances; punctures, for nexample, pleural puncture, etc.).

• Othe day of discharging the child from the hospital, a ‘Discharge form’ is nwritten (the document in which the diagnosis, the prescribed examination, ntreatment and recommendations are specified); it is given out to the parents or ntransferred to the children’s polyclinic.

Theme n3. Technique nof anthropometric measurements in children of all ages.

Measuring nWeight

Technique nof procedure:

Weigh infants nnude on platform-type scale

protect infant nby placing hand above body to prevent falling off scale.

Weigh young nchildren (by 2 years) nude on platform-type scale in sitting position.

Weigh older nchildren in underwear (no shoes) on standing-type upright scale.

Check that scale nis balanced before weighting.

Cover scale with ncleaapkin or sheet of paper for each child.

Measure to the nnearest 10 g or 0.5 ounce for infants and 100 g or 0.25 pound for children.

To have exact nresults weigh children in the morning before first meal, after urination and ndefecation.

Measuring nHeight

Technique nof procedure:

Measure recumbent nlength in children below 12 months. Place supine with head in midline, npinna of the ear must be on an imaginary vertical line with lower eyelid of the neye. Grasp knees and push gently toward table to fully extend legs. Measure nfrom vertex (top) of head to heels of feet (toes pointing upward).

Measure standing nheight (stature) in children over 12 months. Remove socks and shoes. Have nchild stand as tall as possible, back straight, head in midline, lower eyelid nand pinna of the same side ear on one imaginary horizontal line. Check for nflexion of knees, slumping shoulders, rising of heels. Measure from top of head nto standing surface. Measure to the nearest cm or 1/8 inch.

Measuring nhead circumference

Technique nof procedure:

Measure head ncircumference (HC) with paper or steel tape at greatest circumference, from nslightly above the eyebrows and pinna of the ears to occipital prominence of nskull.

Measuring nchest circumference

Technique nof procedure:

Measure chest ncircumference with paper or steel tape around chest at nipple line and under tips nof scapulas at back. Ideally, take measurements during inhalation and nexpiration; record the average of the two values.

Measuring crown-to-rump nlength or sitting height.

Technique nof procedure:

If infants, nplace on side with legs flexed at hips; measure from top of head to rump.

In children able nto sit unsupported, sit against wall and measure from top of head to sitting nsurface.

Sitting height nis 70 % of total body length at birth, 60 % at 2 years, and 52 % at 10 years.

Helpful nin distinguishing dwarfism from small stature.

Anthropometrical nmeasurements and their assessment

Newborns. At nbirth weight is more variable than height and to a greater extent is a reflection of the intrauterine environment. The average nnewborn weighs 3200 to 3400 g (7 nto 7.5 pounds). Admissible limits of the norm ranges from 2700 to 4000 g. Babies, which birth weight equals more than 4000 g, are called huge. Birth length is influenced considerably by the prenatal nenvironment and gestation age. It is of great value as a sign of maturity of nnewborn organism. Its normal rate ieonate is 50 to 52 cm. Admissible limits of the norm ranges from 46 to 56 cm.

Head circumference at birth is equal 34 to 36 cm. Chest circumference equals 32 to 34 cm.

Weight.

Technique nof procedure.

Weigh infants nude on platform-type scale; protect infant nby placing hand above body nto prevent falling off scale. Weigh young children (by 2 years) nude oplatform-type scale in sitting position. Weigh older children in underwear (no shoes) on standing-type upright scale. Check that scale nis balanced before weighting. Cover scale with cleaapkin or sheet of paper nfor each child. Measure nto the nearest 10 g or 0.5 ounce for infants and 100 g or 0.25 pound for children. To have exact results weigh children in the morning before first meal, after urination and defecation.

During first days of child’s life there appears to be a nsmall decrease of body weight that is called physiological loss of weight. The nmaximum weight decrease is 6 to 8 % of birth weight. After the third day of nlife an increase begins, and the renewal of birth weight is observed by the seventh (eighth) day of nlife. But only 20 % of childreshow this ideal type of physiological weight loss. For others it takes more time (approximately till 10-th to 14^th day of nlife) to regain birth weight. This physiologic weight loss represents a loss of nexcessive extracellular fluid and meconium, in addition to relative lack of nfood and fluids intake. The nrate of weight gain increases rapidly for a shot time after birth but soon decreases markedly. By the time the individual reaches nmaturity the birth weight has only increased about 20 times (to 68 kg). In general the birth weight doubles by 4 to 4.5 months of age and triples by the end of the nfirst year. By the end of nthe second year it usually quadruples. After this point the “normal” nrate of weight gain, just as the growth iheight, assumes a steady annual increase of approximately 2 to 2.75 kg per year until the adolescent grows spurt. Boys may add 20 kg and girls 15 kg during the growth spurt.

Weight gain is usually considered to be an indication of nsatisfactory growth progress nin a child and is probably the best index of nutrition and growth. However, nit may be difficult to determine if this increase in weight is caused by healthy tissue development or by an unhealthy ndeposition of tat or accumulation of fluid.

General Trends in Weight and Height Gain During Infancy

Age	Weight gain (grams)		Height gain (cm)
Age	Monthly	For the whole period	Monthly	For the whole period
1.	600	600	3	3
2.	800	1400	3	6
3.	800	2200	3	9
4.	750	2950	2.5	11.5
5.	700	3650	2.5	14
6.	650	4300	2.5	16.5
7.	600	4900	2	18.5
8.	550	5450	2	20.5
9.	500	5950	2	22.5
10.	450	6400	1-1.5	23.5-24
11.	400	6800	1-1.5	24.5-25
12.	350	7150	1-1.5	25.5-27

Height

Technique of procedure.

Measure recumbent length in children below 12 months. nPlace supine with head in midline, pinna of the ear must be on an imaginary nvertical line with lower eyelid of the eye. Grasp knees and push gently toward table to nfully extend legs. Measure from vertex (top) of head to heels of feet (toes npointing upward).

Measure standing height (stature) in children over 12 nmonths. Remove socks and shoes. nHave child stand as tall as possible, back straight, head in midline, lower eyelid nand pinna of the same side ear on one imaginary horizontal line. Check for flexion of knees, slumping shoulders, rising of nheels. Measure from top of head to standing nsurface. Measure to the nearest cm or 1/8 inch.

Linear growth occurs almost entirely as a result of nskeletal growth and is considered to be a nstable measure of general growth. Growth in height is not uniform throughout life, but when maturation of nthe skeleton is complete, linear growth nceases. The maximum growth in length occurs before birth, but the newborn continues to grow at a rapid, though nslower, rate. As the month pass, the ngrowth rate rapidly decelerates. By 2 years of age the child normally nhas achieved 50 % of his adult height. In average yearly height gain at age 2 nor 3 years is 8 cm.

General nTrends in Weight and Height Gain During Childhood

Age	Weight	Height
Toddlers (1-4 years)	Birth weight quadruples by age 2.5 years Yearly gain: 2 kg	Height at age 2 is approximately 50 % of eventual adult height Yearly gain: 8 cm
Preschoolers (4-6 years)	Yearly gain: 2 kg	Birth length doubles by age 4 Yearly gain: 6 cm
School-age children	10 years old child weighs in average 30 kg Yearly gain: 2 kg	Yearly gain: 6 cm Birth length triples by about age 13
Pubertal growth spurt
Females – 10-14 years	Yearly gain: 4 kg	Height gain: 16 cm
Males – 11-16 years	Yearly gain: 4 kg	Height gain: 20 cm
Empirical formulas:	2 -10 years: W=10+2n; 10-16 years: W=30+4(n-10), or W=2n+8 (kg), where- age of child in years	1-4 years: H=100-8(4-n); 5-15 years: H= 100+6(n-4), or H=6n+80 (cm), where- age of child in years

Thus nby age 4 birth length has usually doubled and is equal to 100 cm. Then the child begins a relatively stable and steady growth rate of 5 to 6 cm per year that continues for the next 7 to 8 years. (Occasionally a child will exhibit a transitory midgrowth height increase at age 6 or 7). This long midgrowth period is ended by a sudden and marked acceleration – nthe adolescent growth spurt. Although there is wide variation, this increase, nwhich begins about 10.5 to 11 in girls and 12.5 to 13 in boys, lasts approximately 2 to 2.5 years. During this time a boy may add 20 cm to his height and a girl 16 cm. Usually, 98 % of the terminal height is reached by age 16.5 in girls but not until age 17.5 in boys.

Head ncircumference.

Technique nof procedure.

Measure head circumference n(HC) with paper or steel tape at greatest circumference, from slightly above nthe eyebrows and pinna of the ears to occipital prominence of skull.

General ntrends in head circumference gain during childhood are the next:

Infant n

Birth-6 nmonths – monthly ngain: 1.5 cm

6-12 nmonths – monthly ngain: 0.5 cm

Children

1-5 years – yearly gain: 1 cm

6-15 nyears – yearly ngain: 0.6 cm

If anthropometrical measurements at birth are unknown it nis comfortably to use such empirical nformulas:

· nHead circumference nfor children from birth till 6 months:
nHC=43-1.5x(6-n), where- age nof child in months.

· nHead circumference nfor children from 6 till 12 months:

HC=43+0.5x(n-6), where- age of child in months.

· nHead circumference nfor children from 1 till 5 years:

HC=50-lx(5-n), where- age of child in years.

· nHead circumference nfor children from 5 till 15 years:
nHC = 50+0.6x(n-5), where n-age nof child in years.

Chest circumference

Technique of procedure.

Measure chest circumference with paper or steel tape naround chest at nipple line and under tips of scapulas at back. Ideally, take nmeasurements during inhalation and expiration; record the average of the two nvalues.

General trends in chest circumference gain during nchildhood are the next:

Infants

Birth – 6 months – monthly ngain: 2 cm

6-12 months – monthly gain: 0.5 cm

Children

1 n- 10 years – yearly ngain: 1.5 cm

11-15 years n- yearly gain: 3 cm

If anthropometrical measurements at birth are unknown it nis comfortably to use such empirical nformulas:

· nChest ncircumference for children from birth till 6 months:
nChC=45-2x(6-n), where- age nof child in months.

· nChest ncircumference for children from 6 till 12 months:
nChC=45+0,5x(n-6), where nn – age of child in months.

· nChest ncircumference for children from 1 till 10 years:
nChC=63-l .5x(10-n), where- nage of child in years.

· nChest ncircumference for children from 10 till 15 years:
nChC=63+3x(n-10), where- age nof child in years.

It is necessary to compare head circumference and chest ncircumference. At birth HC exceeds chest circumference by 2 to 3 cm. At age 4 months HC equals chest circumference. Later, the rate of chest circumference increases rapidly, at the same time HC continues to grow at a slower rate. So, during nchildhood chest circumference nexceeds HC by about 1 to 7 cm.

Assessment of physical development of the child

To nvalue the proportionality and harmony of physical development of a child nanthropometrics indexes are used.

1. nThe index of fatness by Chulitska ncan be calculated for children of first 8 years of life. n

I=3´shoulder circumference+thigh circumference+shicircumference-height (stature) (cm)

Normal ndata according to age:

Infants	20-25 cm
Toddlers	20 cm
Preschoolers	10-15 cm
8 year child	Decreases to 6 cm

Decrease of this index shows on hypothrophia, exhaustion or ngreat height. Its increase shows on paratrophy (obesity) or considerable delay nof growth.

2. nThe index by Erismann ncan be calculated for children by 15 years. n

IE=chest ncircumference-½ height (cm)

Normal ndata according to age:

Infants	13,5 – 10 cm
Toddlers	9 –6 cm
Preschoolers	4 – 2 cm
School-age children	0 cm
Teenagers	1 – 3 cm

Decrease of this index, especially its negative meanings is nthe sign of dysproportionality of physical growth (excessive linear growth). nConsiderable increase of this index shows on dwarfism or small stature.

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For nevaluating of physical development percentile tables are used. nMeasurements of length, weight and HC between the 25^th and 75^th npercentiles are likely to represent normal growth. Measurements between the 10^th nand 25^th percentiles represent less than average data and betweethe 75^th and 90^th – bigger than average data. These nmeasurements may or may not be normal, depending on previous and subsequent nmeasurements and on genetic and environmental factors. Measurements between the n10^th and 3d, and the 90^th and 97^th percentiles nbelong to low and high data, which require further examination. Measurements nbelow the 3^rd and above the 97^th percentiles are nextremely low and extremely high and reflect pathological deviations of nphysical development.

The ngrowth data must remain generally within the same percentile, except during nrapid growth periods. In this case physical development is evaluated as nproportional.

Serial nmeasurements of growth are plotted periodically on standard growth charts nto determine the pattern of growth and to compare the individual child growth nwith the norm for that particular age group (See Growth Charts). The growth nchart is a presentation of normal growth in terms of curves plotted along npercentile levels. The true growth pattern is reflected in the velocity ncurve, which is derived from measurements at regular intervals from the ndistance curve. For example, a child may fall below the 3^rd npercentile on a distance curve, whereas the child’s rate of gain over time may nactually be withiormal limits. Children do not have as strong tendency to nremain in the same percentile position on velocity curves as they do odistance curves. There is a pattern of moving from outer percentile positions ntoward more central positions. During adolescence the “typical” distance curves nare misleading because the percentile ranges of growth vary remarkably. If the nchild matures early, he moves to a higher percentile before dropping back to nhis preadolescent percentile. Conversely, if a child matures late, he moves to na lower percentile before regaining at maturity his preadolescent percentile.