Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Individuals who experienced childhood sexual or physical abuse are at increased risk for developing bulimia nervosa 200MDI beconase aq visa quick allergy treatment. Childhood obesity and early pubertal maturation increase risk for bulimia nervosa buy discount beconase aq on-line food allergy treatment guidelines. Familial transmission of bulimia nervosa may be present buy beconase aq 200MDI allergy testing st cloud mn, as well as genetic vulnerabilities for the disorder. Severity of psychiatric comorbidity predicts worse long-term outcome of bulimia nervosa. C ulture-Related Diagnostic issues Bulimia nervosa has been reported to occur with roughly similar frequencies in most in dustrialized countries, including the United States, Canada, many European countries, Australia, Japan, New Zealand, and South Africa. In clinical studies of bulimia nervosa in the United States, individuals presenting with this disorder are primarily white. However, the disorder also occurs in other ethnic groups and with prevalence comparable to esti mated prevalences observed in white samples. G ender-Related Diagnostic issues Bulimia nervosa is far more common in females than in males. Males are especially under represented in treatment-seeking samples, for reasons that have not yet been systemati cally examined. However, several labora tory abnormalities may occur as a consequence of purging and may increase diagnostic certainty. These include fluid and electrolyte abnormalities, such as hypokalemia (which can provoke cardiac arrhythmias), hypochloremia, and hyponatremia. The loss of gastric acid through vomiting may produce a metabolic alkalosis (elevated serum bicarbonate), and the frequent induction of diarrhea or dehydration through laxative and diuretic abuse can cause metabolic acidosis. Some individuals with bulimia nervosa exhibit mildly ele vated levels of serum amylase, probably reflecting an increase in the salivary isoenzyme. However, inspection of the mouth may reveal significant and permanent loss of dental enamel, especially from lin gual surfaces of the front teeth due to recurrent vomiting. In some individuals, the salivary glands, particularly the parotid glands, may become notably enlarged. Individuals who induce vomiting by manually stimulating the gag reflex may develop calluses or scars on the dorsal surface of the hand from re peated contact with the teeth. Serious cardiac and skeletal myopathies have been reported among individuals following repeated use of syrup of ipecac to induce vomiting. Comprehensive evaluation of individuals with this disorder should include assessment of suicide-related ideation and behaviors as well as other risk factors for suicide, including a history of suicide attempts. Functional Consequences of Buiimia Nervosa Individuals with bulimia nervosa may exhibit a range of functional limitations associated with the disorder. A minority of individuals report severe role impairment, with the so cial-life domain most likely to be adversely affected by bulimia nervosa. Individuals whose binge-eating behav ior occurs only during episodes of anorexia nervosa are given the diagnosis anorexia ner vosa, binge-eating/purging type, and should not be given the additional diagnosis of bulimia nervosa. For individuals with an initial diagnosis of anorexia nervosa who binge and purge but whose presentation no longer meets the full criteria for anorexia nervosa, binge-eating/purging type. Some individuals binge eat but do not engage in regular inap propriate compensatory behaviors. In certain neurological or other medical conditions, such as Kleine-Levin syndrome, there is disturbed eating behavior, but the characteristic psycho logical features of bulimia nervosa, such as overconcem with body shape and weight, are not present. Overeating is common in major de pressive disorder, with atypical features, but individuals with this disorder do not engage in inappropriate compensatory behaviors and do not exhibit the excessive concern with body shape and weight characteristic of bulimia nervosa. Binge-eating behavior is included in the impulsive be havior criterion that is part of the definition of borderline personality disorder. If the cri teria for both borderline personality disorder and bulimia nervosa are met, both diagnoses should be given. Comorbidity Comorbidity with mental disorders is common in individuals with bulimia nervosa, with most experiencing at least one other mental disorder and many experiencing multiple co morbidities. Comorbidity is not limited to any particular subset but rather occurs across a wide range of mental disorders. In many individuals, the mood disturbance begins at the same time as or following the development of bulimia nervosa, and individ uals often ascribe their mood disturbances to the bulimia nervosa. However, in some in dividuals, the mood disturbance clearly precedes the development of bulimia nervosa. These mood and anxiety disturbances frequently remit follow ing effective treatment of the bulimia nervosa. The lifetime prevalence of substance use, particularly alcohol or stimulant use, is at least 30% among individuals with bulimia ner vosa. A substan tial percentage of individuals with bulimia nervosa also have personality features that meet criteria for one or more personality disorders, most frequently borderline personality disorder. The binge-eating episodes are associated with three (or more) of the following: 1. The binge eating is not associated with the recurrent use of inappropriate compensa tory behavior as in bulimia nen/osa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. Specify if: In partial remission: After full criteria for binge-eating disorder were previously met, binge eating occurs at an average frequency of less than one episode per week for a sustained period of time. In full remission: After full criteria for binge-eating disorder were previously met, none of the criteria have been met for a sustained period of time. Specify current severity: the minimum level of severity is based on the frequency of episodes of binge eating (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability. Diagnostic Features the essential feature of binge-eating disorder is recurrent episodes binge eating that must occur, on average, at least once per week for 3 months (Criterion D). An "episode of binge eating" is defined as eating, in a discrete period of time, an amount of food that is defi nitely larger than most people would eat in a similar period of time under similar circum stances (Criterion Al).
Blood and urine monitoring in otherwise healthy and mazepine; data for phenytoin and phenobarbital are similar discount beconase aq on line allergy shots gone wrong. Presumptive biochemical disorders development of polycystic ovaries; and the possible effect of b purchase generic beconase aq line allergy shots zyrtec. History of significant adverse drug reactions ing oral contraceptives increases the risk that contraception buy 200MDI beconase aq otc allergy symptoms urticaria. Those unable to communicate require a different being used and of the need that the contraceptive contain an strategy adequate amount of estrogen (19). For newly introduced drugs, follow recommended cific drug causes polycystic ovary syndrome has generated guidelines for blood monitoring until the numbers of continued discussion (22). Either anovulatory cycles with patients treated in this country increase and data become serologic evidence or physical changes of androgen excess can available. Clinical risk patterns: summary and hyperandrogenism are associated with valproate, high perrecommendations. Idiosyncratic Reactions to Valproate: Clinical Risk Patterns and Mechanisms of centages of ovarian changes have been reported in women Toxicity. Psychiatric serum amylase and lipase disorders have occurred and drug-induced lupus has been (pancreatitis), ammonia, plasma, and urine carnitine assay reported in children (32). Oxcarbazepine Serum sodium Topiramate Urine for microscopic hematuria Felbamate and renal ultrasound (renal stones), intraocular pressure (glaucoma) Felbamate, a dicarbamate compound related to meprobamate, Zonisamide Urine for microscopic hematuria and involves vigorous drug interactions that may cause clinically renal ultrasound (renal stones) significant toxic reactions or exacerbate seizures (33). Before felbato get in touch with the physician, and the physician must mate is prescribed, manufacturer recommendations should be facilitate that communication. Hepatotoxic effects of felbamate seem less monitoring may be recommended in the materials developed clearly associated with risk factors. It may be wise Guidelines now emphasize that felbamate should be used to follow those guidelines until broader clinical experience is for severe epilepsy refractory to other therapy. Women with autoimmune disease account for the largest proPatients and care givers must be alerted to this problem and portion of those who developed aplastic anemia. Hydration of the epoxide Gabapentin, 1-(aminomethyl)cyclohexane acetic acid, is strucoccurs through microsomal epoxide hydrolase. Adverse events that enzyme, as with concomitant administration of valproic were typically neurotoxic, but withdrawal from studies was acid, increases the quantity of the epoxide (30). Use in mentally retarded children was accompaSevere reactions to carbamazepine can cause hematopoietic, nied by an increased incidence of hyperactivity and aggressive skin, hepatic, and cardiovascular changes (17). Transient leukopenia is observed in 10% to 12% of patients; however, fatal reactions such as aplastic anemia are Central nervous system side effects included lethargy, fatigue, rare. Patients and parents must be reassured that frequent monand mental confusion (36–38). Serious rash appears to be coritoring of blood counts and liver values is unnecessary (2). Morbilliform erythematous rash, urticaria, or a macuOxcarbazepine was associated with malformations in a small lopapular pattern are most common (39–44); however, erycohort of a study that failed to identify phenytoin as causing thema multiforme and blistering reactions like Stevens–Johnson malformations (27). Cross-reactivity in patients allergic to syndrome or toxic epidermal necrolysis can occur. Such sensitivity reactions often include fever, lymphadenopathy, elevated liver enzyme values, and altered numPhenobarbital bers of circulating cellular elements of blood (42). Most serious rashes developed within failure, agranulocytosis, and aplastic anemia. Long-term treatment may cause connective tissue changes, More than 80% of patients who experienced a serious rash with coarsened facial features, Dupuytren contracture, were being treated with valproate or had been given higherLedderhose syndrome (plantar fibromas), and frozen shoulder than-recommended doses (42). Sedative effects may exacerbate absence, atonic, and drug interaction with valproate, which inhibits the metabomyoclonic seizures. Sudden withholding of doses of shortlism of lamotrigine, causing diminished clearance and resulacting barbiturates may precipitate drug-withdrawal seizures tant high blood levels (43). Phenobarbital’s slow rate of clearfollowed, the incidence of serious rash may be reduced ance makes such acute seizures less of a problem, but dose (42,44,45). In the United States, discontinuation is advised if tapering is recommended if discontinuation is planned. Infants of mothers treated with phenobarbital may have irritability, hypotonia, and vomLevetiracetam iting for several days after delivery (56). Behavioral changes reported in children include aggression, emotional lability, Phenytoin is a weak organic acid, poorly soluble in water, and oppositional behavior, and psychosis (47). Because of the drug’s pre-existing tendency has been suggested as a mechanism (48), saturation kinetics, small changes in the maintenance dose but behavioral changes consistent with all of the newer drugs produce large changes in total serum concentration (57); thus, have been reported as well (49). DoseOxcarbazepine related effects of phenytoin include nystagmus, ataxia, altered coordination, cognitive changes, and dyskinesia. Facial feaOxcarbazepine is a keto analogue of carbamazepine that is tures may coarsen, and body hair may change texture and rapidly converted to a 10-monohydroxy active metabolite by darken. Osteoporosis and lymphadenopathy occur with longlite correlates with measured creatinine clearance. Folate deficiency may be severe enough to cause sedation, and fatigue, possibly dose related, were reported in megaloblastic anemia; a transient encephalopathy is said to pivotal trials (50–52). Allergic dermatitis, hepatotoxicity, serum sickness, need for polytherapy at any age. Drug-induced lupus Most cases of fatal liver failure involved mental retardaerythematosus reactions have been observed (60). Two of four reported patients older than age 21 years had degenerative disease of the nervous system. Nine of 16 hepatic fataliTopiramate ties in one report (77), and all members of the 11to 20-yearold age group in another series were neurologically abnormal. The drug Only 7 of 26 adults with fatal hepatic failure were considered appears to influence sodium and a portion of chloride neurologically normal (78).
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The cyclothymic disorder diagnosis is not made if the pattern of mood swings is better explained by schizoaffective disorder cheap beconase aq online master card allergy testing veterinary, schizophrenia buy 200MDI beconase aq amex allergy medicine not strong enough, schizophreniform disorder best buy for beconase aq allergy treatment xanthelasma, delu sional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders (Criterion D), in which ease the mood symptoms are considered asso ciated features of the psychotic disorder. The mood disturbance must also not be attribut able to the physiological effects of a substance. Although some individ uals may function particularly well during some of the periods of hypomania, over the prolonged course of the disorder, there must be clinically significant distress or impair ment in social, occupational, or other important areas of functioning as a result of the mood disturbance (Criterion F). The impairment may develop as a result of prolonged pe riods of cyclical, often unpredictable mood changes. In the general population, cyclothymic disorder is apparently equally common in males and females. In clinical settings, females with cyclothymic disorder may be more likely to present for treatment than males. Deveiopment and Course Cyclothymic disorder usually begins in adolescence or early adult life and is sometimes considered to reflect a temperamental predisposition to other disorders in this chapter. Onset of persistent, fluctuating hypomanie and de pressive symptoms late in adult life needs to be clearly differentiated from bipolar and related disorder due to another medical condition and depressive disorder due to another medical condition. Cyclotiiymic disorder may be more common in the first-degree biological relatives of individuals witiK bipolar I disorder than in the general population. Differentiai Diagnosis Bipolar and related disorder due to another medical condition and depressive disorder due to another medical condition. The diagnosis of bipolar and related disorder due to another medical condition or depressive disorder due to another medical condition is made when the mood disturbance is judged to be attributable to the physiological effect of a specific, usually chronic medical condition. This determination is based on the history, physical examination, or laboratory findings. If it is judged that the hypomanie and depressive symptoms are not the physiological consequence of the med ical condition, then the primary mental disorder. For example, this would be the case if the mood symptoms are considered to be the psychological (not the physiological) consequence of having a chronic medical condition, or if there is no etiological relationship between the hypomanie and de pressive symptoms and the medical condition. Substance/medication-induced bipolar and related disorder and substance/medica tion-induced depressive disorder. Substance/medication-induced bipolar and related disorder and substance/medication-induced depressive disorder are distinguished from cyclothymic disorder by the judgment that a substance/medication (especially stimu lants) is etiologically related to the mood disturbance. The frequent mood swings in these disorders that are suggestive of cyclothymic disorder usually resolve following cessation of substance/medication use. Both disorders may resemble cyclothymic disorder by virtue of the frequent marked shifts in mood. Borderline personality disorder is associated with marked shifts in mood that may suggest cyclothymic disorder. If the criteria are met for both disorders, both borderline personality disorder and cyclothymic disorder may be di agnosed. Most children with cyclothymic disorder treated in outpatient psychiatric settings have comorbid mental conditions; they are more likely than other pediatric patients with mental disorders to have comorbid attention-deficit/hyperactivity disorder. A prominent and persistent disturbance in mood that predominates inthe clinical picture and is characterized by elevated, expansive, or irritable mood, with or without depressed mood, or markedly diminished interest or pleasure in all, or almost all, activities. The disturbance is not better explained by a bipolar or related disorder that is not sub stance/medication-induced. Such evidence of an independent bipolar or related disor der could include the following: the symptoms precede the onset of the substance/medication use; the symptoms per sist for a substantial period of time. The disturbance causes clinically significant distress or impairment in social, occupa tional, or other important areas of functioning. The name of the substance/medication-induced bipolar and related disor der begins with the specific substance. The diagnostic code is selected from the table in cluded in the criteria set, which is based on the drug class. For example, in the case of irritable symptoms occurring during intoxication in a man with a severe cocaine use disorder, the diagnosis is 292. The diagnostic code is selected from the table in cluded in the criteria set, which is based on the drug class and presence or absence of a comorbid substance use disorder. When recording the name of the disorder, the comorbid substance use disorder (if any) is listed first, followed by the word "with," followed by the name of the substance-induced bipolar and related disorder, followed by the specification of onset. For example, in the case of irritable symptoms oc curring during intoxication in a man with a severe cocaine use disorder, the diagnosis is F14. If the substance-induced bipolar and related disorder occurs without a comorbid substance use disorder. When more than one substance is judged to play a significant role in the development of bipolar mood symptoms, each should be listed separately. Diagnostic Features the diagnostic features of substance/medication-induced bipolar and related disorder are es sentially the same as those for mania, hypomania, or depression. A key exception to the diag nosis of substance/medication-induced bipolar and related disorder is the case of hypomania or mania that occurs after antidepressant medication use or other treatments and persists be yond the physiological effects of the medication. This condition is considered an indicator of true bipolar disorder, not substance/medication-induced bipolar and related disorder. Simi larly, individuals with apparent electroconvulsive therapy-induced manic or hypomanie ep isodes that persist beyond the physiological effects of the treatment are diagnosed with bipolar disorder, not substance/medication-induced bipolar ^ d related disorder. That is, the criterion symptoms of mania/hypomania have specificity (simple agitation is not the same as excess involvement in purposeful activities), and a sufficient number of symptoms must be present (not just one or two symptoms) to make these diagnoses. In particular, the appearance of one or two nonspecific sjonptoms—irritability, edginess, or agitation during antidepressant treatment—in the absence of a full manic or hypomanie syndrome should not be taken to support a diagnosis of a bipolar disorder.
Often cheap 200MDI beconase aq mastercard allergy forecast dayton oh, work together to purchase beconase aq mastercard allergy shots lymph nodes develop child care licensing requirements when faced with the pressures of the workplace order beconase aq with a mastercard allergy testing does it work, parents/ and guidelines for children who are ill. To meet this responsibility, health departness, children need familiar caregivers/teachers and familiar ments generally have the expertise to provide leadership places where their illnesses and their emotional needs can and technical assistance to licensing authorities, caregivers/ be managed competently. The heavy reliance on the expertise of local and state health departments in the 10. In addition, the business commuognized by the state child care regulatory agency should nity has a vested interest in assuring that parents/guardians credential or license all persons who provide child care or have facilities that provide quality care for children who are who may be responsible for children or who may be alone ill so parents/guardians can be productive in the workplace. The credential should be granted this vested interest is likely to produce meaningful contributo individuals who meet age, education, and experience tions from the business community to creative solutions and qualifcations, whose health status facilitates providing safe innovative ideas about how to approach the regulation of and nurturing care, and who have no record of conviction facilities for children who are ill. All stakeholders in the care for criminal offenses against persons, especially children, of children who are ill should be involved for the solutions or confrmed act of child abuse. The state should establish that are developed in regulations to be most successful. The current system, in which the details background checks of a prospective employee and without of staff qualifcations and ongoing training are checked as having to hire before background checks have been compart of facility inspection, is cumbersome for child care adpleted. By this means, children are not exposed to health ministrators and licensing inspectors alike. If staff qualifcaand safety risks from understaffng, or to care by unqualitions were established as part of a separate, more central fed or even dangerous individuals employed provisionally process, the licensing agency staff could check center because the results of a check are not yet available to the records of character references and whether staff members director. Nursery crimes: over quality, encourage a career ladder with increasing qualSexual abuse in day care. Such Every state should have a statute which mandates the a process is analogous to that provided for other education licensing agency or other authority to obtain a background professionals (teachers), and even those service providers screening that includes a criminal records check, a sex with less potential for harm than is involved in caring for offender registry check, and a child abuse registry check children (such as beauticians, barbers, taxi drivers). The expense of background screenings should be administrators, licensors, and child care personnel, who do a public responsibility. No staff (paid or volunteer) or family not have to undertake the tedious process of verifcation member should be unsupervised with the children until all of each portion of an individual’s credentials during all site background screenings have been completed and found to visits, when sites are licensed, or when individuals change be acceptable. Public and private policymakers should use fnancial care providers who care for just a few children. Caregivers/ and other incentives to help caregivers/teachers meet creteachers who care for more children are required to comply dentialing requirements. In nearly all States, colleges to offer courses appropriate for provider training regulations require background screenings for all child at times convenient for child care workers to attend and for care center staff. This screening requirement may protect other agencies to offer online courses available to providers children from abuse and reduce liability risks (1). The requirement for renewable certifcation they have been implemented, has become an additional is likely to deter people from applying for work in child care fnancial burden on programs, which are forced to pass as a way of gaining access to children for sexual purposes on the expense to parents/guardians or staff. Placing the since the process would include a background screening burden on potential new staff, volunteers, and substitute that includes a check of the sex offender registry and child caregivers/teachers themselves proves to be another disinabuse registry (1). For workers who enter the feld as a tion of credit-bearing courses that have been previously frst work experience, previous child abuse histories may approved as meeting the state’s requirements to a central be unknown. In many cases juvenile records are sealed and verifcation offce where this transcript should be continually cannot be used for the purposes of background screenupdated. Most state by state licensing agency staff for evidence of behavior that regulations are not clear on whether sex offender registries would disqualify an individual for work in specifed child are to be checked (2). Evidence of a recent health examination indicatSome states have established defnitions for regular voling ability to care for children can be submitted at the same unteers (for whom criminal record and child abuse registry time. The center director then knows whether job applicants checks should be required) and for short-term visitors, such who have been working in the feld previously are qualifed as entertainers and others, who will not be unsupervised at the time they apply for the job, without lengthy waiting for with the children. Informaical and emotional abuse may or may not be the purview of tion on how to call and how to report should be posted in the licensing agency. This responsibility may fall to another licensed facilities so it is readily available to parents/guardagency to which the licensing agency refers child abuse ians and staff. This responsibility may fall to another agency to Public authorities (such as licensing agencies) and private which the licensing agency refers child abuse allegations. The chief sources of technical technical assistance should also be provided related to their assistance are: state’s child abuse/neglect statute and procedures includa) Licensing agencies (on ways to meet the regulations); ing the facility’s responsibilities of reporting suspected child b) Health departments (on health related matters); abuse and neglect. Regulations should be available to parents/guardians and State agencies should encourage the arrangement and interested citizens upon request and should be translated if coordination of and the fscal support for consultants from needed. Licensing inspectors throughout the state should the local community to provide technical assistance for probe required to offer assistance and consultation as a regular gram development and maintenance. Consultants should part of their duties and to coordinate consultation with other have training and experience in early childhood education, technical assistance providers as this is an integral part of early childhood growth and development, issues of health the licensing process. Child care staff is rarely trained health range for other public agencies, private organizations or professionals. Since staff and time are often limited, caregivtechnical assistance agencies (such as a resource and referers/teachers should have access to consultation on availral agency) to make the following consultants available to able resources in a variety of felds (such as physical and the community of child care providers of all types: mental health care; nutrition; safety, including fre safety; a) Program consultant, to provide technical assistance oral health care; developmental disabilities; and cultural for program development and maintenance and sensitivity) (1,2). Consultants should be chosen the public agencies can facilitate access to children and on the basis of training and experience in early their families by providing useful materials to child care childhood education and ability to help establish links providers. The pediatrician’s role in make consultants accessible to facilities for ongoing promoting health and safety in child care. Child c) Nutritionist/registered dietitian, who also has the care health consultation improves health and safety policies and knowledge of infant and child development, food practices. The written agreement of small family child care homes in partnering with should be available at the time of an inspection visit. Early Childhood Education Consultants locating the appropriate materials and tools.
Gun storage closet or under a bed when faced with fre discount beconase aq generic allergy shots reactions swelling, leading to quality beconase aq 200MDI allergy medicine you can take with high blood pressure fatalipractices and risk of youth suicide and unintentional frearm injuries order beconase aq overnight delivery allergy medicine makes symptoms worse. When children leave the facility risk are printed on diaper-pail bags, dry-cleaning bags, and for a walk or to be transported, a designated staff member so forth. If present in a d) Non-glass, non-mercury thermometer to measure a small or large family child care home, these items must be child’s temperature; unloaded, equipped with child protective devices, and kept e) Bandage tape; under lock and key with the ammunition locked separately f) Sterile gauze pads; 257 Chapter 5: Facilities Caring for Our Children: National Health and Safety Performance Standards g) Flexible roller gauze; care program (1). Contact the local poison center at 1-800h) Triangular bandages; 222-1222 for instructions if needed. Pediatric frst aid for with supervision, if hands are not visibly soiled or if caregivers and teachers. Department of Health and Human Services, Offce of the Assistant Secretary for Planning and s) Individually wrapped sanitary pads to contain Evaluation. The shared use of a towel should ing each child and ensuring that the staff members are able be prohibited. Cracks in the skin and excessive dryness from the vehicle is used to take a child to or from a center, or frequent handwashing discourage the staff from complying for outings. Maps are required in case transporting staff with necessary hygiene and may lead to increased bacteneed to fnd an alternate way back to the facility or another rial accumulation on hands. The availability of hand lotion route to emergency services when roads are closed and/or to prevent dryness encourages staff members to wash their communication and power systems are inaccessible. Supplies must be within arm’s reach of grams may want to have access to hand-held or stationary the user to prevent contamination of the environment with electronic/cellular, or satellite devices. Disshould not be included in frst aid kits or available at a child posable towels prevent this problem, but once used, must Chapter 5: Facilities 258 Caring for Our Children: National Health and Safety Performance Standards be discarded. Liquid soap is widely available, economical, and easily Family Child Care Home used by staff and children. Sustainable Hospitals Project, University of Massachusetts– this special need should be used. Sustainable Hospitals Project, University of Massachusetts– out having to touch the container or the fresh towel supply Lowell. If clean reusable rags are used, they paint can be ingested in suffcient quantities to cause lead should be laundered separately between each one-time use poisoning (1,2,3). The lead-safe traditional loop mop method, yet there is a reduction in the certifed guide to renovate right. The system leaves only a light Outdoor Areas flm of water on the foor that dries quickly, thus lessening the potential for worker injury for slips and falls on a wet All outdoor activity areas should be maintained in a clean foor. Materials used for cleaning become contaminated in and safe condition by removing: the process and must be handled so they do not spread a) Debris; potentially infectious material (3). Delegated staff s) Cisterns; members should actively look for faking or peeling paint t) Cesspools; while cleaning the exterior areas. If faking/peeling paint is u) Unprotected utility equipment; found, it should be tested for lead. Each Lead paint chips may be ingested by young children and playground is unique and requires a routine maintenance lead to neurological and behavioral problems. Low level lead exposure harms children: A renewed call for Outdoor areas should be kept free of excessive dust, primary prevention. Spilled dry foods could attract rodent to children by barriers, or removed until rendered safe or and insects. The physical structure where children spend each involve water should be cleaned and disinfected according day can present caregivers/teachers with special safety to manufacturers’ instructions. To get the most could cause falls and other injury, and broken glass winbeneft, the facility should follow all instructions. National Institute of Building issues alert about care of room humidifers: Safety alert. Facilities that do not have on-site play areas outdoor space by providing a large indoor play area (see but that use playgrounds and equipment in adjacent parks Standard 6. Architectural and Transportation Barriers Compliance Board *These areas may be further sub-divided into ages two to (U. Social and environmental factors associated with the outdoor playground should include an open space for preschoolers’ nonsedentary physical activity. An aggregate size of greater than Indoor Play Area 4,200 square feet that includes all of a facility’s playgrounds If a facility has less than seventy-fve square feet of acceshas been associated with signifcantly greater levels of chilsible outdoor space per child or provides active play space dren’s physical activity (5). This follows the when open windows are not possible; developmental ages used for the development of the Stanc) the surfaces and fnishes are shock-absorbing, as dards for play equipment for children. The fence should be a) Ages six through twenty-three months designed to prevent children from climbing it. An approved b) Ages two to fve years* fre escape should lead from the roof to an open space at c) Ages fve to twelve years** the ground level that meets the safety standards for outdoor *These areas may be further sub-divided into ages two to play areas. Jurisdictions vary inner-city areas or areas with extreme weather with an between fourand six-foot fence heights. This space could be a dedicated gross motor room running along the top of the retaining wall. The room should provide feet, a fence not less than six feet high should be installed. Before indoor signed so all spaces are less than three and one-half inches areas are used for gross motor activity, a heating and air (1).