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Except for newborns gastritis with hemorrhage discount 20mg protonix, the ratio of chest compressions to gastritis diet of hope generic 40 mg protonix otc ventilathe director of a center or a large family child care home tions in the 2010 guidelines is 30:2 gastritis in english generic 20mg protonix with mastercard. Use of cardiopulmonary z) Organizing and implementing a plan to gastritis symptoms duration order protonix 40mg fast delivery meet an resuscitation by North Carolina day care providers. To ensure the health and safety of children in a child care setting, someone who is Aid Training qualifed to respond to common injuries and life-threatFirst aid training should present an overview of Emergency ening emergencies must be in attendance at all times. First aid instruction should to ensure the safety of children, can reduce the potential for include, but not be limited to, recognition and frst response death and disability. Such caregivers/teachers must have pedic) Bleeding, including nosebleeds; atric frst aid competence. Parental notifcation and comand inhaled; munication with emergency medical services must be careg) Puncture wounds, including splinters; fully planned. During drowning, of training should be evident by the change in performance cold exposure provides the possibility of protection of the as measured by accreditation standards or other quality asbrain from irreversible damage associated with respiratory surance systems. The difference between a life and death situation teaching tasks, caregivers/teachers must attain multifaceted is the submersion time. Planning and evaluation of training Studies have shown that prompt rescue and the presence of should be based on performance of the staff member(s) a trained resuscitator at the site can save about 30% of the involved. Too often, staff members make training choices victims without signifcant neurological consequences (1). Therefore, caregiver/ and Water Play teacher change in behavior or the continuation of appropriStandard 2. Staff members who are better trained are better able to prevent, recognize, and correct health and safety problems. The number of training hours recommended in this standard refects the central focus of caregivers/teachers on child development, health, and safety. Children may come to child care with identifed special health care needs or special needs may be identifed while attending child care, so staff should be trained in recognizChapter 1: Staffng 26 Caring for Our Children: National Health and Safety Performance Standards ing health problems as well as in implementing care plans in child care settings and to comfort an injured child and for previously identifed needs. Successful sional development based on the needs of the program and completion of training can be measured by a performance the pre-service qualifcations of staff (1). Training should test at the end of training and by ongoing evaluation of address the following areas: performance on the job. Decisions about management of infant and early childhood nutrition, school-age child nutriill children are facilitated by skill in assessing the extent to tion, prescribed nutrition therapies, food service and food which the behavior suggesting illness requires special mansafety issues in the child care setting. All caregivers/teachers should early childhood and child care, facilities might negotiate for be trained to prevent, assess, and treat injuries common 27 Chapter 1: Staffng Caring for Our Children: National Health and Safety Performance Standards this individual to serve or identify someone to serve as a Projects and Outreach: Early Childhood Research and consultant and trainer for the facility. Some resources education of staff and fourteen indicators of quality from a to contact include: study conducted in four Midwestern states. Standards for early childhood professional o) Local community colleges and trade schools. Health services in child care day care (frequently bilingual) or audiovisual materials prepared or centers: A survey. Department of Health and Human Caregivers/teachers should have a basic knowledge of Services, Offce of the Assistant Secretary for Planning and special health care needs, supplemented by specialized Evaluation. Managing infectious of special health care needs of the children in care should diseases in child care and schools: A quick reference guide. Teachers Financial support and accessibility to training programs Small family child care home caregivers/teachers should requires attention to facilitate compliance with this standard. These training opportunities can also be conage mix of children, and continuity of caregiver/teacher, ducted on site at the child care facility. Completion of trainthe training/education of caregivers/teachers is a specifc ing should be documented by a college transcript or a trainindicator of child care quality (1). Most skilled roles require ing certifcate that includes title/content of training, contact training related to the functions and responsibilities the hours, name and credentials of trainer or course instructor role requires. Whenever possible the submission of training are more likely to decrease morbidity and mortality documentation that shows how the learner implemented in their setting (3) and are better able to prevent, recognize, the concepts taught in the training in the child care program and correct health and safety problems. Although on-site training can be Children may come to child care with identifed special costly, it may be a more effective approach than participahealth care needs or may develop them while attending tion in training at a remote location. Because of the nature of their caregiving/teaching tasks, caregivers/teachers must attain multifaceted knowledge and Small family child care home caregivers/teachers should skills. Child health and employee health are integral to any maintain current contact lists of community pediatric primaeducation/training curriculum and program management ry care providers, specialists for health issues of individual plan. Planning and evaluation of training should be based on children in their care and child care health consultants who performance of the caregiver/teacher. These training choices based on what they like to learn about training alternatives provide more fexibility for caregivers/ (their “wants”) and not the areas in which their performance teachers who are remote from central training locations or should be improved (their “needs”). Nevertheless, gathering family child care work alone and are solely responsible for the health and home caregivers/teachers for training when possible prosafety of small numbers of children in care. Peer review is vides a break from the isolation of their work and promotes part of the process for accreditation of family child care and networking and support. Satellite training via down links at can be valuable in assisting the caregiver/teacher in the local extension service sites, high schools, and community identifcation of areas of need for training. Self-evaluation colleges scheduled at convenient evening or weekend times may not identify training needs or focus on areas in which is another way to mix quality training with local availability the caregiver/teacher is particularly interested and may be and some networking. Department of Health and Human k) Organizing the home for child care; Services, Offce of the Assistant Secretary for Planning and l) Preventing unintentional injuries in the home (falls, Evaluation. The director of a and parents/guardians; center or a large family child care home or the designated r) Socio-emotional and mental health (positive apsupervisor for food service should be a certifed food proproaches with consistent and nurturing relationships); tection manager or equivalent as demonstrated by complets) Evacuation and shelter-in-place drill procedures; ing an accredited food protection manager course. Small t) Occupational health hazards; family child care personnel should secure training in food u) Infant-safe sleep environments and practices; service and safety appropriate for their setting. Some of maltreatment can increase the likelihood of appropriate these outbreaks have led to fatalities and severe disabilities. Child and referral agencies, licensing agencies, and state departabuse and children with disabilities: A New York State perspective. The dangers of shaking requirements; infants and toddlers and repeated exposure to domestic d) Program policies and procedures regarding exposure violence should be included in the education and prevento blood/body fuid; tion materials. Caregivers/teachers should also receive e) Reporting procedures under the exposure control education on promoting protective factors to prevent child plan to ensure that all frst-aid incidents involving maltreatment. Caregivers/teachers should be able to identify exposure are reported to the employer before the end signs of stress in families and assist families by providing of the work shift during which the incident occurs (1). Split lips, scraped knees, and other minor injuries associated with bleeding are common in child care. Caregivers/teachers should be trained in compliCaregivers/teachers who are designated as responsible for ance with their state’s child abuse reporting laws. Child rendering frst aid or medical assistance as part of their job abuse reporting requirements are known and available from duties are covered by the scope of this standard. Department of Labor, Occupational Safety and Health work-related duties, such as caring for children or answerAdministration. For guage, and ethnic backgrounds of children enrolled in the small family child care home caregivers/teachers, released program. In addition, all staff members should participate in time and compensation while engaged in training can be diversity training that will ensure respectful service delivery arranged only if the small family child care home caregiver/ to all families and a staff that works well together (2). Center for the Child Care Workforce, American Federation of diverse early childhood workforce. Wage data: Early childhood workforce hourly for quality: the critical importance of developing and supporting wage data. Directors of centers and large family child care homes should arrange for continuing education that is paid for by the government, by charitable organizations, or by the 1. A majorrequired professional development (that includes training ity of child care workers earnings are at or near minimum as well as education) during work hours, or reimburse staff wage (1). This training should out licenses/certifcates should work under direct superviinclude the opportunity for an evaluation and a repeat demsion and should not be alone with a group of children. In all child care settings the A substitute should complete the same background screenorientation should be documented. Decisions should be made on whether a parent/ oriented on the following topics: guardian will be allowed to provide needed on-site media) Safe infant sleep practices if an infant is enrolled in cal services. Substitutes should be aware of the care plans the program; (including emergency procedures) for children with special b) Any emergency medical procedure/medication needs health care needs. Planning for a competent substitute pool is a) the names of the children for whom the caregiver/ essential for child care operation. Since closing a child care home has a d) Acceptable methods of discipline; negative impact on the families and children they serve, syse) Meal patterns and safe food handling policies of the tems should be developed to provide qualifed alternative facility (special attention should be given to lifehomes or substitutes for family child care home caregivers/ threatening food allergies); teachers.

Individuals with bulimia nervosa exhibit recurrent episodes of binge eating congestive gastritis definition order 20mg protonix with mastercard, engage in inappropriate behavior to gastritis zucchini purchase genuine protonix on line avoid weight gain gastritis symptoms and treatment mayo clinic purchase protonix 40mg with amex. However gastritis diet recipes protonix 40 mg lowest price, unlike individuals with anorexia nervosa, binge-eating/purging type, individuals with bulimia nervosa main­ tain body weight at or above a minimally normal level. Individuals with this disorder may exhibit significant weight loss or significant nutritional deficiency, but they do not have a fear of gaining weight or of becoming fat, nor do they have a disturbance in the way they expe­ rience their body shape and weight. Comorbidity Bipolar, depressive, and anxiety disorders commonly co-occur with anorexia nervosa. Many individuals with anorexia nervosa report the presence of either an anxiety disorder or symptoms prior to onset of their eating disorder. Alcohol use disorder and other substance use disorders may also be comorbid with anorexia nervosa, especially among those with the binge-eating/purging type. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. Specify if: In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time. In full remission: After full criteria for bulimia nervosa 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 inappropriate compensatory behaviors (see below). Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate compensatory behav­ iors per week. Diagnostic Features There are three essential features of bulimia nervosa: recurrent episodes of binge eating (Criterion A), recurrent inappropriate compensatory behaviors to prevent weight gain (Criterion B), and self-evaluation that is unduly influenced by body shape and weight (Criterion D). To qualify for the diagnosis, the binge eating and inappropriate compensa­ tory behaviors must occur, on average, at least once per week for 3 months (Criterion C). An "episode of binge eating" is defined as eating, in a discrete period of time, an amount of food that is definitely larger than most individuals would eat in a similar period of time under similar circumstances (Criterion Al). For example, a quantity of food that might be regarded as excessive for a typical meal might be consid­ ered normal during a celebration or holiday meal. A "discrete period of time" refers to a limited period, usually less than 2 hours. For example, an individual may begin a binge in a restaurant and then continue to eat on returning home. Continual snacking on small amounts of food throughout the day would not be considered an eating binge. An occurrence of excessive food consumption must be accompanied by a sense of lack of control (Criterion A2) to be considered an episode of binge eating. Some indi­ viduals describe a dissociative quality during, or following, the binge-eating episodes. The impairment in control associated with binge eating may not be absolute; for example, an individual may continue binge eating while the telephone is ringing but will cease if a roommate or spouse unexpectedly enters the room. If individuals report that they have abandoned efforts to control their eating, loss of control should be considered as present. The type of food consumed during binges varies both across individuals and for a given individual. Binge eating appears to be characterized more by an abnormality in the amount of food consumed than by a craving for a specific nutrient. Individuals with bulimia nervosa are typically ashamed of their eating problems and attempt to conceal their symptoms. The binge eating often continues until the individual is uncomfortably, or even painfully, full. Other triggers include interpersonal stressors; dietary restraint; negative feelings related to body weight, body shape, and food; and boredom. Binge eating may minimize or mit­ igate factors that precipitated the episode in the short-term, but negative self-evaluation and dysphoria often are the delayed consequences. Another essential feature of bulimia nervosa is the recurrent use of inappropriate com­ pensatory behaviors to prevent weight gain, collectively referred to as purge behaviors or purging (Criterion B). Many individuals with bulimia nervosa employ several methods to compensate for binge eating. The immediate effects of vomiting include relief from physical discomfort and re­ duction of fear of gaining weight. In some cases, vomiting becomes a goal in itself, and the individual will binge eat in order to vomit or will vomit after eating a small amount of food. Individuals with bulimia nervosa may use a variety of methods to induce vomiting, includ­ ing the use of fingers or instruments to stimulate the gag reflex. Individuals generally become adept at inducing vomiting and are eventually able to vomit at will. Individuals with bulimia nervosa may misuse enemas following epi­ sodes of binge eating, but this is seldom the sole compensatory method employed. Individ­ uals with this disorder may take thyroid hormone in an attempt to avoid weight gain. Individuals with diabetes mellitus and bulimia nervosa may omit or reduce insulin doses in order to reduce the metabolism of food consumed during eating binges. Individuals with bulimia nervosa may fast for a day or more or exercise excessively in an attempt to prevent weight gain. Exercise may be considered excessive when it significantly interferes with im­ portant activities, when it occurs at inappropriate times or in inappropriate settings, or when the individual continues to exercise despite injury or other medical complications. Individuals with bulimia nervosa place an excessive emphasis on body shape or weight in their self-evaluation, and these factors are typically extremely important in determining self-esteem (Criterion D). Individuals with this disorder may closely resemble those w^ith anorexia nervosa in their fear of gaining weight, in their desire to lose weight, and in the level of dissatisfaction with their bodies. However, a diagnosis of bulimia nervosa should not be given when the disturbance occurs only during episodes of anorexia nervosa (Cri­ terion E). Between eating binges, individuals with bulimia ner­ vosa typically restrict their total caloric consumption and preferentially select low-calorie ("diet") foods while avoiding foods that they perceive to be fattening or likely to trigger a binge. Menstrual irregularity or amenorrhea often occurs among females with bulimia ner­ vosa; it is uncertain whether such disturbances are related to weight fluctuations, to nu­ tritional deficiencies, or to emotional distress. The fluid and electrolyte disturbances resulting from the purging behavior are sometimes sufficiently severe to constitute med­ ically serious problems. Rare but potentially fatal complications include esophageal tears, gastric rupture, and cardiac arrhythmias. Serious cardiac and skeletal myopathies have been reported among individuals following repeated use of syrup of ipecac to induce vom­ iting. Individuals who chronically abuse laxatives may become dependent on their use to stimulate bowel movements. Gastrointestinal symptoms are commonly associated with bulimia nervosa, and rectal prolapse has also been reported among individuals with this disorder. Prevalence Twelve-month prevalence of bulimia nervosa among young females is 1%-1. Point prevalence is highest among young adults since the disorder peaks in older adolescence and young adulthood. Less is known about the point prevalence of bulimia nervosa in males, but bulimia nervosa is far less common in males than it is in females, with an ap­ proximately 10:1 female-to-male ratio. Development and Course Bulimia nervosa commonly begins in adolescence or young adulthood. The binge eating frequently begins during or after an episode of dieting to lose weight. Experiencing multiple stressful life events also can pre­ cipitate onset of bulimia nervosa. Disturbed eating behavior persists for at least several years in a high percentage of clinic samples. The course may be chronic or intermittent, with periods of remission alternating with recurrences of binge eating.

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Cooper and other consultants mentioned below symptoms of gastritis in cats buy protonix 20mg otc, and involved a large number of centres (listed on pages xx-xx) whose work was coordinated by Field Trial Coordinating Centres gastritis diet 1234 purchase protonix 40mg without prescription. The Coordinating Centres gastritis diet cookbook purchase 20mg protonix with visa, listed below and on pages xx-xx gastritis kronik aktif adalah cheap 40 mg protonix overnight delivery, also undertook the task of producing equivalent versions of Diagnostic criteria for research in the languages used in their countries. Wilson conscientiously and efficiently handled the innumerable administrative tasks linked to the field tests and other activities related to the project. Mrs Ruthbeth Finerman, associated professor in anthropology, provided the information upon which Appendix 2: Culture-specific disorders, is based. Frances allowed an extensive exchange of views and helped in ensuring compatibility between the texts. Bertelsen, Institute of Psychiatric Demography, Psychiatric Hospital, University of Aarhus, 8240 Risskov, Denmark Dr D. Caetano, Department of Psychiatry, Universidade Estadual de Campinas Caixa Postal 1170, 13100 Campinas, S. Dilling, Klinik fur Psychiatrie der Medizinischen Hochschule, Ratzeburger Allee 160, 2400 Lubeck, Germany Dr M. Gelder, Department of Psychiatry, Oxford University Hospital, Warneford Hospital, Old Road, Headington, Oxford, United Kingdom Dr D. Kemali, Istituto di Psichiatria, Prima Facolta Medica, Universita di Napoli, Largo Madonna della Grazie, 80138 Napoli, Italy Dr J. Mellsop, the Wellington Clinical School, Wellington Hospital, Wellington 2, New Zealand Dr Y. Nakane, Department of Neuropsychiatry, Nagasaki University, School of Medicine, 7-1 Sakamoto-Machi, Nagasaki 852, Japan Dr A. Okasha, Department of Psychiatry, Ain Shams University, 3 Shawarby Street, Kasr-El-Nil, Cairo, Egypt Dr Ch. Pull, Service de Neuropsychiatrie, Centre Hospitalier de Luxembourg, 4, rue Barble, Luxembourg, Luxembourg Dr D. Regier, Director, Division of Clinical Research, Room 10-105, National Institute of Mental Health, 5600 Fishers Lane, Rockville, Md. Tzirkin, All Union Research Centre of Mental Health, Institute of Psychiatry, Academy of Medical Sciences, Zagorodnoye Shosse d. Takahashi, Department of Psychiatry, Tokyo Medical and Dental University, 5-45 Yushima, 1-Chome, Bunkyoku, Tokyo, Japan Dr N. Wig, Regional Adviser for Mental Health, World Health Organization Regional Office for the Eastern Mediterranean, P. This increases the likelihood of obtaining homogenous groups of patients but limits the generalizations that can be made. Researchers wishing to study the overlap of disorders or the best way to define boundaries between them may therefore need to supplement the criteria so as to allow the inclusion of atypical cases depending upon the purposes of the study. Appendix 1 (pxx) contains suggestions for criteria for some of these exceptions; their placement in an Appendix implies that although their present status is somewhat controversial or tentative, further research on them is to be encouraged. There are a few unavoidable exceptions, the most obvious being Dementia, Simple Schizophrenia and Dissocial Personality Disorder. Once the decision had been made to include these somewhat controversial disorders in the classification, it was considered best to do so without modifying the concepts. Experience and further research should show whether these decisions were justified. For many of the disorders of childhood and adolescence, some form of interference with social behaviour and relationships is included amongst the diagnostic criteria. But a close examination of the disturbances that are being classified in F8 and F9 shows that social criteria are needed because of the more complicated and interactive nature of the subject matter. Children often show general misery and frustration, but rarely produce specific complaints and symptoms equivalent to those that characterise the more individually conceptualised disorders of adults. Many of the disorders in F8 and F9 are joint disturbances which can only be described by indicating how roles within the family, school or peer group are affected. The problem is apparent rather than real, and is caused by the use of the term "disorder" for all the sections of Chapter V(F). The term is used to cover many varieties of disturbance, and different types of disturbance need different types of information to describe them. The criteria are labelled with letters or numbers to indicate their place in a hierarchy of generality and importance. General criteria that must be fulfilled by all members of a group of disorders (such as the general criteria for all varieties of dementia, or for the main types of schizophrenia) are labelled with a capital G, plus a number. Obligatory criteria for individual disorders are labelled by capitals only (A,B,C, etc. To avoid the use of "and/or", when it is specified that either of two criteria is required, then it is always assumed that the presence of both criteria also satisfies the requirement. The two Appendices to this volume deal with disorders of uncertain or provisional status. Appendix 1 contains some affective disorders that have been the subject of recent research, and some personality disorders that although regarded as clinically useful in some countries, are of uncertain status from an international viewpoint. It is hoped that their inclusion here will encourage research concerning their usefulness. Appendix 2 contains provisional descriptions of a number of disorders that are often referred to as "culture specific". The considerable practical difficulties involved in doing field studies of persons with these disorders are recognised, but the provision of these descriptions may act as a stimulus to research by those with a knowledge of the languages and cultures concerned. Training in the use of these instruments can at present be obtained in the following languages: Chinese, Danish, Dutch, English, French, German, Greek, Hindi, Kannada, Portuguese, Spanish, Tamil and Turkish. Evidence of each of the following: (1) A decline in memory, which is most evident in the learning of new information, although in more severe cases, the recall of previously learned information may be also affected. The decline should be objectively verified by obtaining a reliable history from an informant, supplemented, if possible, by neuropsychological tests or quantified cognitive assessments. The severity of the decline, with mild impairment as the threshold for diagnosis, should be assessed as follows: Mild: a degree of memory loss sufficient to interfere with everyday activities, though not so severe as to be incompatible with independent living (see comment on cultural aspects of "independent living" on page 24). For example, the individual has difficulty in registering, storing and recalling elements in daily living, such as where belongings have been put, social arrangements, or information recently imparted by family members. Moderate: A degree of memory loss which represents a serious handicap to independent living. The individual is unable to recall basic information about where he lives, what he has recently been doing, or the names of familiar persons. Severe: a degree of memory loss characterized by the complete inability to retain new information. Evidence for this should be obtained when possible from interviewing an informant, supplemented, if possible, by neuropsychological tests or quantified objective assessments. Deterioration from a previously higher level of performance should be established. The severity of the decline, with mild impairment as the threshold for diagnosis, should be assessed as follows: Mild. The decline in cognitive abilities causes impaired performance in daily living, but not to a degree making the individual dependent on others. The decline in cognitive abilities makes the individual unable to function without the assistance of another in daily living, including shopping and handling money. The decline is characterized by an absence, or virtual absence, of intelligible ideation. The overall severity of the dementia is best expressed as the level of decline in memory or other cognitive abilities, whichever is the more severe. When there are superimposed episodes of delirium the diagnosis of dementia should be deferred. A decline in emotional control or motivation, or a change in social behaviour, manifest as at least one of the following: (1) emotional lability; (2) irritability; (3) apathy; (4) coarsening of social behaviour. For a confident clinical diagnosis, G1 should have been present for at least six months; if the period since the manifest onset is shorter, the diagnosis can only be tentative. Comments: the diagnosis is further supported by evidence of damage to other higher cortical functions, such as aphasia, agnosia, apraxia. Judgment about independent living or the development of dependence (upon others) need to take account of the cultural expectation and context.

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Other Small jerks of the limbs may be misperceived as myoclonus gastritis diet ĺâđîńďîđň buy protonix on line, variants of migraine that may be confused with seizures and the child may have fecal incontinence gastritis weakness order protonix 20 mg fast delivery. The behavior include cyclic vomiting (abdominal pain) gastritis diet čăđŕňü buy generic protonix 20 mg online, acute confusional resolves with treatment of the chronic constipation gastritis poop buy protonix with paypal. Recurrent Abdominal Pain Rage Attacks Recurrent abdominal pain may be associated with vomiting, the episodic dyscontrol syndrome, or recurrent attacks of pallor, or even fever and has been noted in migraine and rage following minimal provocation, may be seen in children epilepsy. The behavior often seems completely although some children with recurrent abdominal pain or out of character. Rage may be more common in hyperactive vomiting may experience migraine later in life (7,84). Ictal rage is these patients have a diagnosis of seizures, and more than 40% rare, unprovoked, and usually not directed toward an individhave recurrent headaches (7). Following attacks of rage and the appearance of near found in approximately 20% (82). Although most of these psychosis, the child resumes a normal state and may recall children do not respond to antiepileptic drugs, approximately the episode and feel remorseful. Behavior frequently can be 20% obtain relief from antimigraine medications such as modified during the event. Migraine may present in an unusual and sometimes bizarre fashion as confusion, hyperactivity, partial or total amnesia, disoriMunchausen Syndrome by Proxy entation, impaired responsiveness, lethargy, and vomiting (85). Munchausen syndrome, or factitious disorder, describes a these episodes must be distinguished from toxic or metabolic consistent simulation of illness leading to unnecessary investiencephalopathy, encephalitis, acute psychosis, head trauma, and gations and treatments. When a parent or caregiver pursues sepsis as well as from an ictal or postictal confusional state. Infants may be brought to commonly for days, and spontaneously clears following sleep. Accompanying symptoms may include gastroinmay demonstrate regional slowing, a nondiagnostic finding. Sometimes the child also becomes persuaded of the reality of the “illness” and Obstructive outflow develops independent factitious symptoms such as psyCerebrovascular chogenic seizures. The parent’s exaggerated and constant need for illness and medical intervention may lead to the minor trauma, or being in a warm, crowded place often elicits child’s death. Orthostatic syncope may follow prolonged standTreatment is similar to that of child abuse and typically ing or sudden change in posture. The family history may disinvolves a pediatrician, child psychiatrist, nurse, and social close similar events (96). The child is separated from the parents, and details coughing, swallowing, or micturition (97). Admission of a occurring late in syncope complicates the picture, but a full hischild with paroxysmal symptoms to an epilepsy monitoring tory usually elucidates the cause (81). Good relationships with the nonabusive father, blood pressure of more than 15 points or sinus bradycardia (or successful short-term foster parenting before return to the both) on rapid standing is highly suggestive of orthostatic mother or long-term placement with the same foster parents, hypotension. A search for arrhythmia and murmur is warlong-term treatment or successful remarriage of the mother, ranted, as cardiac causes of syncope are primarily obstructive and early adoption are associated with more favorable outlesions or arrhythmias not otherwise clinically evident (97,98). Syncope associated with ophthalmoplegia, retinitis pigmentosa, deafness, ataxia, or seeming myopathy mandates an urgent evaluation for heart block (Kearns–Sayre syndrome) (99). Wakefulness Narcolepsy and Cataplexy Syncope Narcolepsy is a state of excessive daytime drowsiness causing Syncope is common in adolescents or older children and usurapid brief sleep, sometimes during conversation or play; the ally can be distinguished from seizures by description. Narcolepsy also includes signs of lightheadedness, dizziness, and visual dimming (“graysleep paralysis (transient episodes of inability to move on ing out” or “browning out”) occur in most patients. Nausea is awakening) and brief hallucinations on arousal along with common before or after the event, and a feeling of heat or cold cataplexy, although not all patients demonstrate the complete and profuse sweating are frequent accompaniments. Narcolepsy may be many as 10% to 20% of children with congenital heart disease, treated with a stimulant drug (102–104). In “tet” spells, Cataplexy produces a sudden loss of tone with a drop to young children with tetralogy of Fallot squat nearly motionless the ground in response to an unexpected touch or emotional during exercise as their cardiac reserve recovers (110). Consciousness is not lost during Children and adults with shunted hydrocephalus may have these brief attacks. Obstruction associated with the third ventricle or aqueduct may cause the Basilar Migraine bobble-head doll syndrome (two to four head oscillations per Most common in adolescent girls, basilar migraine begins second) in mentally retarded children (112). In hydrocephalic with a sudden loss of consciousness followed by severe occipipatients treated by ventricular shunting, acute decompensatal or vertex headache. Dizziness, vertigo, bilateral visual loss, tion may increase seizure frequency or give rise to symptoms and, less often, diplopia, dysarthria, and bilateral paresthesias, misdiagnosed as seizures. A history of headache or a family history of characterized by tonic, opisthotonic postures frequently assomigraine is helpful in making the diagnosis. Children may respond to classic migraine therapy or also may indicate increased intracranial pressure, a posterior antiepileptic drugs (105,106). Tremor the episodic nature of periodic paralysis may lead to An involuntary movement characterized by rhythmic oscillamisidentification of the symptoms as epilepsy. Familial and tions of a particular part of the body, tremor may appear at sporadic cases typically are associated with disorders of rest or with only certain movements. Acetazolamide is useful in sionally mistaken for seizure activity, particularly when the some forms of the disorder (113). The exact clinical presentation of cerebrovascuand during activities, possibly by manipulating the affected lar disorders in both children and adults depends primarily on body part while observing the tremor, usually can define the the size and location of the brain lesion and on the etiology movement by varying or obliterating the tremor. Transient ischemic troencephalogram is unchanged as the tremor escalates and attacks, episodes of ischemic neurologic deficits lasting less diminishes (107). Symptoms begin suddenly following an embolus, Panic attacks may occur as acute events associated with a with the deficit reaching maximum severity almost immedichronic anxiety disorder or in patients suffering from depresately. Symptomatology is characteristically separated and are accompanied by palpitations, sweating, dizziness or into carotid artery syndromes with symptoms of middle cerevertigo, and feelings of unreality. The latter also have been noted: dyspnea or smothering sensations, are most common in adults with longstanding hypertension unsteadiness or faintness, palpitations or tachycardia, tremand may be characterized by pure motor hemiparesis or bling or shaking, choking, nausea or abdominal distress, monoparesis and isolated hemianesthesia. Vertebrobasilar depersonalization or derealization, numbness or tingling, syndromes, especially transient ischemic attacks, may be misflushes or chills, chest pain or discomfort, and fears of dying, taken for epilepsy because of recurrence and duration and aura, going crazy, or losing control. An electroencephalogram may present with ataxia, dysarthria, nausea, vomiting, vertigo, recorded at the time of the attacks differentiates ictal fear and and even coma. The subclavian steal synPanic disorders involve spontaneous panic attacks and may drome is associated with stenosis or occlusion of the subclabe associated with agoraphobia. Although they may begin in vian artery proximal to the origin of the vertebral artery. Retrograde flow through the vertebral artery into the postPsychiatric therapy is indicated (109). Vertigo, ataxia, syncope, Acute fugue, phobias, hallucinations, and autistic behavand visual disturbance occur intermittently when blood is iors may seem to represent seizures; however, associated feadiverted into the distal subclavian artery. Besides blood products, air emboli, foreign-body embolism Several disease states include recurrent symptoms that are miswith pellets, needles, or talcum, or fat emboli may be noted. Episodes of cyanosis, dyspnea, and In adults, carotid and vertebrobasilar occlusion with or unconsciousness followed by a convulsion may occur in as without embolization is typically associated with systemic Chapter 40: Other Nonepileptic Paroxysmal Disorders 503 cerebrovascular disease. Infantile nystagmus: a occur on the basis of both largeand small-vessel abnormalities prospective study of spasmus nutans, congenital nystagmus, and unclassiassociated with sickle cell disease, symptoms may vary. Startle disorders of man: hyperexplexia, A variety of paroxysmal happenings may be confused with jumping and startle epilepsy. Startle disease or hyperexbefore, during, and after the spell; age of onset; time of occurplexia: further delineation of the syndrome. Shuddering attacks in children: an early video recordings of the episodes may be extremely helpful. Alternating hemiplegia of childhood: a study of 10 patients and results of flunarizine treatment. Neurologic Emergencies in Infancy and malities should be reviewed to modify the interpretation of Childhood. Seizures and other paroxysmal disorders in gastroesophageal reflux: a specific clinical syndrome. Respiratory sinus arrhythmia in children Differential Diagnosis in Epilepsy: A Comprehensive Textbook. Jitteriness beyond the neonatal (nocturnal myoclonus): relation to sleep disorders. Development of behavioral and emotional and adolescents: outcome after diagnosis by ictal video and electroenproblems in Tourette syndrome. Tilt test for diagnosis of tive features distinguishing epileptic from nonepileptic events. These new drugs have provided patients with with known genetic defects that resemble the human condiincreased seizure control; are proven to be better tolerated; and tion.