By E. Keldron. Olivet Nazarene University. 2018.

Water Treatment Manual: Disinfection Keep accurate records for audit and justification of outcomes super cialis 80 mg with mastercard erectile dysfunction quran. A common way of ranking risk is through a scoring system which categorises the likelihood and consequence separately purchase super cialis 80 mg line xylitol erectile dysfunction, and combining these in a frequency/consequence matrix, Table 8. Alkalinity: The quantitative capacity of water to neutralize an acid; that is, the measure of how much acid can be added to a liquid without causing a significant change in pH. This capacity is caused by the amount of bicarbonate, carbonate, and hydroxide compounds present in the water Alkalinity is not the same as pH because water does not have to be strongly basic (high pH) to have high alkalinity. A flat board or plate, wall, deflector, guide or similar device constructed or placed in flowing water to cause more uniform flow velocities, to absorb energy, and to divert, guide, or agitate water. Barrier: A treatment or disinfection process that constitutes an impediment to the transmission of waterborne pathogenic microorganisms or other contaminants to humans in drinking water. The term barrier encompasses treatment and disinfection processes that either remove or inactivate such microorganisms and contaminants. The three forms of free chlorine exist together in equilibrium, the relative portions of which are determined by the pH value and temperature. This is the parameter used which is monitored downstream of contact tank as C for calculation of the Ct value necessary for the verification of primary disinfection systems. Combined chlorine can be accurately estimated as the difference between the measured total chlorine and measure or known free chlorine residual. Total; Total chlorine residual equal the sum of free chlorine residual and combined chlorine residual Clarifier: A large circular or rectangular treatment process tank through which water is passed upwards for a period of time, during which the heavier suspended solids or coagulated floc particles (including colloidal particles bound up therein) are removed from the water. Colloidal: A type of very small, finely divided particulate matter ranging in size from approximately 2 - 1,000 nm in diameter, which can be present in water. Colloids do not settle out rapidly and remain dispersed in a liquid for a long time due to their small size and electrical charge. Repulsion of similarly charged particles can prevent the particles from becoming heavier and settling out. Colour: Colour in water may result from a number of sources including metallic ions (iron and manganese), and particulate and dissolved organic material. Conventional A method of treating water which consists of the addition of coagulant chemicals, Treatment: flash mixing, coagulation, flocculation (not necessarily in separate tanks or basins), clarification, by sedimentation or flotation and filtration, resulting in substantial particulate removal. Ct: The product of “residual disinfectant concentration” (C) in mg/l determined before or at the first customer, and the corresponding “disinfectant contact time” (t) in minutes, expressed in mg. This Ct value is widely utilised in international standards and guidance on disinfection practice for the establishment of target log inactivation for various pathogens and is used in practice to determine the disinfectant concentration” (C) necessary to achieve the target inactivation given the available contact arrangements. Cryptosporidium: A disease-causing protozoon widely found in surface water sources. Cryptosporidium is spread by the fecal-oral route as a dormant oocyst from human and animal faeces. In its dormant stage, Cryptosporidium is housed in a very small, hard-shelled oocyst form that is environmentally robust and very resistant to chlorine and chloramine disinfectants. When water containing these oocysts is ingested, the protozoa replicates within the intestinal tract of the host causing a severe gastrointestinal illness called cryptosporidiosis. Cryptosporidiosis: The gastrointestinal illness caused by infection with cryptosporidium. Disinfectant Any chemical oxidant, including but not limited to chlorine, chlorine dioxide, chloramines, and ozone which is added to water in any part of the treatment or distribution process and which is intended to kill or inactivate pathogenic microorganisms. The intensity of the reddish tint to the water formed in the sample relates directly to the amount of disinfectant such as free chlorine, chlorine dioxide and/or permanganate, present in the sample. These bacteria, which are of definite faecal origin (human and animal), are excreted in vast numbers and their presence in a water supply is proof that faecal contamination has occurred and is a definite indication that pathogens may be present. Epidemiology: The study of the occurrence and causes of health effects in human populations. Filtration: A treatment process for removing particulate matter from water by passage through porous media Water Treatment Manual: Disinfection Floc: In drinking water treatment, floc refers to the fine cloud of spongy particles that form in water to which a coagulant has been added. Flocculation: A process to enhance agglomeration or collection of smaller floc particles into larger, more easily settleable particles through gentle stirring by hydraulic or mechanical means following chemical addition of aluminium or iron salts and polyelectrolytes. Hardness: Hardness in water, usually expressed in mg/l CaCo3 is the measure of the concentration of dissolved calcium and magnesium salts, particularly carbonates and bicarbonates. There is no health risk associated with hard water, however, it can be difficult to lather and can cause scaling problems in hot water systems Headloss: The head, pressure or energy lost by water flowing in a pipe, in a channel or through a tank as a result of turbulence caused by the velocity of the flowing water and the roughness of the pipe, channel walls or restrictions caused fittings. Water flowing in a pipe or channel loses head, pressure or energy as a result of friction losses. The head loss through a filter is due to friction losses caused by material building up on the surface or in the interstices of the filter media. When water containing these cysts is ingested by a new host, the protozoa cause a severe gastrointestinal illness called giardiasis. Granular The term refers to Activated Carbon: a) the highly porous adsorbent filter media which is produced by heating coal or wood in the absence of air prior to crushing the material into granulated form approximately 1mm in size b) the constituent element of a water treatment process by which treatment process water is passed through such media. Activated carbon is positively charged and therefore able to remove negative ions from the water such as chlorine and ozone and is recognised as an effective method of reducing dissolved organics and associated taste and odour problems in water by adsorption.

Neck pain improved in both treat- Nunley eal46 conducd a prospective random- mengroups order super cialis 80mg on-line erectile dysfunction at 18, bustatistically signifcanimprove- ized controlled trial comparing the clinical and ra- ments were nod in the Prestige group asix weeks discount super cialis 80mg with mastercard erectile dysfunction vacuum pump demonstration, diographic outcomes of patients tread with one- three months and 12 months. Asysm maintained physiological segmental motion mean follow-up of 16 months, 49 patients (73. Fusion patients had a higher secondary nifcantly shorr in the arthroplasty group than the surgery ra and higher medication usage postop- fusion group. Segmental mo- Tis clinical guideline should nobe construed as including all proper methods of care or excluding other acceptable methods of care reasonably direcd to obtaining the same results. Of the pain rating index scores signifcantly decreased for 95 surgically tread patients, 52 received a cervical all three groups immedialy afr surgery and con- inrverbral fusion cage and 51 received a Cloward tinued to decline, plaauing aabouone year. Using multivaria analysis, the variables� in- McGill pain scores markedly improved immedialy fuence on projection showed thathe mosimpor- afr surgery and continued to improve until the one tanpreoperative variables for predicting short-rm year follow-up evaluation before plaauing. Pa- logical fnding and surgical chnique exceppre- tients included in the study were enrolled adifer- operative kyphosis were insignifcanas predictors enpoints in their disease and received surgery aof both short- and long-rm outcome. All scores im- very small sample size of nonrandomized patients proved in the group operad on atwo-levels. All thaModifed Million Index and Oswestry Index are 38 patients included in the study received physical clinically useful tools in the evaluation of outcome therapy and were assessed aa mean of 21. Status Questionnaire, Sickness ImpacProfle, Modifed Million Index, McGill Pain Scores and Davis eal17 conducd a retrospective observa- Modifed Oswestry Disability Index are suggest- tional study assessing the outcome of posrior de- ed outcome measures for assessing treatmencompression for cervical radiculopathy. Of the 170 of cervical radiculopathy from degenerative dis- patients included in the study, patients who had orders. In 86% of patients, outcome was 1 good (defned as a Prolo score of 8 in 5%, 9 in 38% Alrawi eal repord the fndings of a prospective and 10 in 43%). Prolo scale is more objective and quantitative than Of the 20 patients included in the study, eighshowed Tis clinical guideline should nobe construed as including all proper methods of care or excluding other acceptable methods of care reasonably direcd to obtaining the same results. In the 28 patients included in the study, statistically signifcanimprovements were found Witzmann eal64 described a retrospective observa- in postoperative scores for bodily pain (p<0. Outcomes were assessed athree months, weeks, three months, six months, one year and two six months, nine months and two years. Initially there pain demonstrad by the McGill pain scores signif- was no statistically signifcandiference in pain in- icantly decreased for all three groups immedialy nsity between the surgically and conservatively afr surgery and continued to decline, plaauing tread groups. McGill pain scores markedly im- Modifed Oswestry Disability Index may be appro- proved immedialy afr surgery and continued pria outcome measures for cervical radiculopathy to improve until the one year follow-up evaluation from degenerative disorders tread with surgery. In critique, neither patients nor reviewers were masked to treatmengroup and the Future Directions for Research sample size was small. Outcome measures may be an appropria outcome tool for cervical such as these need to be incorporad into Level I radiculopathy from degenerative disorders tread studies to confrm their validity and to establish with surgery. Of the 46 patients included in the study, come in the surgical treatmenof cervical radiculopathy. Atwo years, 81% of patients were tive diagnostic cervical nerve rooblock--correlation with satisfed with the outcome of surgery. Elective non-instru- levels compared to those who were operad with- mend anrior cervical diskectomy and fusion in Ghana: a preliminary report. Dec 15 2003;28(24):2673- cervical fusion with inrbody titanium cage containing 2678. Jan tive randomized multicenr clinical evaluation of an an- 15 1998;23(2):188-192. Anrior microforaminotomy with pla fxation: a prospective randomized study with for treatmenof cervical radiculopathy: par1--disc-pre- 2-year follow-up. Randomized, pro- or cervical foraminotomy for unilaral spondylotic radic- spective, and controlled clinical trial of pulsed electro- ulopathy. Transforaminal sroid parative analysis of cervical arthroplasty using Mobi-C injections in the treatmenof cervical radiculopathy. Pechlivanis I, Brenke C, Scholz M, EngelhardM, Harders croforaminotomy for cervical radiculopathy. Percutaneous cervical nucleo- outcome of anrior cervical decompression and fusion: a plasty in the treatmenof cervical disc herniation. Sep 16 spondylosis: clinical syndromes, pathogenesis, and man- 2003;25(18):1033-1043. Relationships between outcomes of conser- corpectomy withoufusion: our experience in 48 patients. Use of tion study of the ProDisc-C total disc replacemenver- the Solis cage and local autologous bone graffor anrior sus anrior discectomy and fusion for the treatmenof cervical discectomy and fusion: early chnical experi- 1-level symptomatic cervical disc disease. Medical and Inrventional TreatmenWhais the role of pharmacologi- Whais the role of physical ther- cal treatmenin the managemenapy/exercise in the treatmenof of cervical radiculopathy from de- cervical radiculopathy from de- generative disorders? A sysmatic review of the lirature yielded no stud- A sysmatic review of the lirature yielded no stud- ies to adequaly address the role of pharmacologi- ies to adequaly address the role of physical thera- cal treatmenin the managemenof cervical radicu- py/exercise in the managemenof cervical radicul- lopathy from degenerative disorders. In the surgical group, eighpatients had a second opera- Pharmacological TreatmenReferences tion: six on adjacenlevel, one infection and one 1.

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Treatment professionals act in a partnership/consultation role purchase super cialis 80 mg on-line erectile dysfunction causes cycling, drawing upon each person’s goals and strengths super cialis 80mg with mastercard erectile dysfunction lotions, family supports, and community resources. Three focus areas were aligned to achieve a complete systems transformation in the design and delivery of recovery-oriented services: a change in thinking (concept); a change in behavior (practice); and a change in fscal, policy, and administrative functions (context). These grants have given states, tribes, and community-based organizations resources and opportunities to create innovative practices and programs that address substance use disorders and promote long-term recovery. Valuable lessons from these grants have been applied to enhance the feld, creating movement towards a strong recovery orientation, and highlight the need for rigorous research to identify evidence-based practices for recovery. Through a series of actions and activities, this initiative has served to conceptualize and implement recovery-oriented services and systems across the country; examined the scope and depth of existing and needed recovery supports; supported the growth and quality of the peer workforce; enhanced and extended local, regional, and state recovery initiatives; and supported collaborations and capacity within the recovery movement. Recovery Supports Even after a year or 2 of remission is achieved—through treatment or some other route—it can take 4 to 5 more years before the risk of relapse drops below 15 percent, the level of risk that people in the general population have of developing a substance use disorder in their lifetime. These changes are typically marked and promoted by acquiring healthy life resources—sometimes called “recovery capital. Recovery support services have been evaluated for effectiveness and are reviewed in the following sections. The members share a problem or status and they value experiential knowledge— learning from each other’s experiences is a central element—and they focus on personal-change goals. The groups are voluntary associations that charge no fees and are self-led by the members. First, they have been in existence longer, having originally been created by American Indians in the 18 centuryth after the introduction of alcohol to North America by Europeans. They have been studied extensively for problems with alcohol, but not with illicit drugs. Third, mutual aid groups have their own self-supporting ecosystem that interacts with, but is fundamentally independent of, other health and social service systems. Alcoholics Anonymous and its derivative programs share two major components: A social fellowship and a 12-step program of action that was formulated based on members’ experiences of recovery from severe alcohol use disorders. Members of 12-step mutual aid groups tend to have a history of chronic and severe substance use disorders and participate in 12-step groups to support their long-term recovery. About 50 percent of adults who begin participation in a 12-step program after participating in a treatment program are still attending 3 years later. Any research study that research has moved from correlational studies with no prospectively assigns human participants control groups to carefully conducted randomized controlled or groups of participants to one or more health-related interventions to evaluate trials. These groups do not limit talking time and incorporate cultural traditions and languages. Multiple clinical trials have demonstrated that several clinical procedures are effective in increasing participation in mutual aid groups, and increase the chances for sustained remission and recovery. Health care professionals who help link patients with members of a mutual aid group can signifcantly increase the likelihood that the patients will attend the group. Al-Anon Family Groups Friends and family members often suffer when a loved one has a substance use disorder. This may be due to worry about the loved one experiencing accidents, injuries, negative social and legal consequences, diseases, or death, as well as fear of the loved one engaging in destructive behavior, such as stealing, manipulating, or being verbally or physically aggressive. Consequently, a number of mutual aid groups have emerged to provide emotional support to concerned signifcant others and families and to help them systematically and strategically alter their own unproductive behaviors that have emerged in their efforts to deal with the substance use problems of their affected loved one. Al-Anon is a mutual aid group commonly sought by families dealing with substance use in a loved one. Clinical trials and other studies of Al-Anon show that participating family members experience reduced depression, anger, and relationship unhappiness, at rates and levels comparable to those of individuals receiving psychological therapies. Recovery Coaching Voluntary and paid recovery coach positions are a new development in the addiction feld. Coaches do not provide “treatment” per se, but they often help individuals discharging from treatment to connect to community services while addressing any barriers or problems that may hinder the recovery process. Some community-based recovery organizations offer training programs for recovery coaches, but no national standardized93 approach to training coaches has been developed. A descriptive study of 56 recently homeless veterans with substance use disorder Case management. A coordinated suggested that supplementing psychotherapy with recovery approach to delivering general health coaching increased length of abstinence at follow-up 6 care, substance use disorder treatment, 95 mental health, and social services. Recovery coaches may complement, although approach links clients with appropriate not replace, professional case management services in the services to address specifc needs and child welfare, criminal justice, and educational systems. One large randomized trial showed that providing recovery 1 coaches to mothers with a substance use disorder who were involved in the child welfare system reduced the likelihood of the mother’s child being arrested by 52 percent. Many residents stay in recovery housing during and/or after outpatient treatment, with self-determined residency lasting for several months to years. Residents often informally share resources with each other, giving advice borne of experience about how to access health care, fnd employment, manage legal problems, and interact with the social service system. Some recovery houses are connected with afliates of the National Alliance of Recovery Residences, a non- proft organization that serves 25 regional afliate organizations that collectively support more than 25,000 persons in recovery across over 2,500 certifed recovery residences.

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Note: The presence of blood on the urine test strips does not indicate infection and should be investigated as above safe 80 mg super cialis erectile dysfunction and diabetes medications. If haematuria does not resolve rapidly after treatment referral for formal investigation will be required 80 mg super cialis with amex erectile dysfunction treatment comparison, i. May be associated with both obstructive (weak, intermittent stream and urinary hesitancy) and irritative (frequency, nocturia and urgency) voiding symptoms. Urinary retention with a distended bladder may be present in the absence of severe symptoms, therefore it is important to palpate for an enlarged bladder during examination. For patients presenting with urinary retention, insert a urethral catheter as a temporary measure while patient is transferred to hospital. As the axial skeleton is the most common site of metastases, patients may present with back pain or pathological spinal fractures. It is important, however, to differentiate between nocturnal enuresis and daytime wetting with associated bladder dysfunction. Secondary causes of enuresis include: » diabetes mellitus » urinary tract infection » physical or emotional trauma Note: » Clinical evaluation should attempt to exclude the above conditions. Clinical features of obstructing urinary stones may include: » sudden onset of acute colic, localized to the flank, causing the patient to move constantly, » nausea and vomiting, » referred pain to the scrotum or labium on the same side as the stone moves down the ureter. Antimicrobial resistance patterns in outpatient urinary tract infections--the constant need to revise prescribing habits. Antimicrobial susceptibility patterns of Escherichia coli strains isolated from urine samples in South Africa from 2007-2011. Antimicrobial susceptibility of organisms causing community-acquired urinary tract infections in Gauteng Province, South Africa. A meta-analysis of randomized, controlled trials comparing short- and long-course antibiotic therapy for urinary tract infections in children. The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement. Intensive Care Unit, Royal Children’s Hospital, Parkville, Victoria 3052, Australia. Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled non-inferiority trial. Treatment targets Additional Parameter Optimal Acceptable action suggested Finger-prick blood glucose values:  fasting (mmol/L) 4–7 <8 >8  2-hour post-prandial (mmol/L) 5–8 8–10 >10 Glycosylated haemoglobin (HbA1c) (%) <7 7–8 >8 Blood pressure Systolic <140 mmHg Diastolic <90 mmHg i LoE:I The increased risk of hypoglycaemia must always be weighed against the potential benefit of reducing microvascular and macrovascular complications. Insulin regimens Basal bolus regimen All type 1 diabetics should preferentially be managed with the “basal bolus regimen” i. This consists of pre-meal, short-acting insulin and bedtime intermediate-acting insulin not later than 22h00. The total dose is divided into: o 40–50% basal insulin o The rest as bolus insulin, split equally before each meal. It is a practical option for patients who cannot monitor blood glucose frequently. Drawing up insulin from vials » Clean the top of the insulin bottle with an antiseptic swab. In thin people it may be necessary to pinch the skin between thumb and forefinger of one hand. Prefilled pens and cartridges In visually impaired patients and arthritic patients, prefilled pens and cartridges may be used. However, an increasing number of adolescents are being diagnosed with type 2 diabetes mellitus. Criteria for screening for diabetes in children th » Body mass index > 85 percentile for age and sex. It is difficult to distinguish type 2 from type 1 diabetes mellitus, as many type 1 diabetics may be overweight, or have a family history of type 2 diabetes mellitus, given the increasing prevalence of both obesity and type 2 diabetes mellitus. The diagnosis of type 2 diabetes mellitus in adolescents should be made in consultation with a specialist. Most adults with type 2 diabetes mellitus are overweight with a high waist to hip ratio. In adults the condition might be diagnosed only when presenting with complications, e. Suspect type 1 diabetes mellitus among younger patients with excessive weight loss and/or ketoacidosis. Treatment targets Additional Parameter Optimal Acceptable action suggested Finger prick blood glucose values:  fasting (mmol/L) 4–7 <8 > 8  2-hour post-prandial (mmol/L) 5–8 8–10 > 10 Glycosylated haemoglobin (HbA1c) (%) < 7 7–8 > 8 Blood pressure Systolic < 140 mmHg Diastolic < 90 mmHg » In the elderly, the increased risk of hypoglycaemia must be weighed against the potential benefit of reducing microvascular and macrovascular complications. For treatment of hypertension and dyslipidaemia after risk-assessment, see Section 4. Diet » Consider the following for a person-centred approach to diet therapy:  Weight. These foods are digested slowly resulting in a slow and steady rise in blood glucose concentrations. Fruit and vegetables » Eat a variety of fruit and vegetables – 4 to 5 portions on a daily basis. Insulin type Starting dose Increment Add on 10 units in the evening before If 10 units not effective: therapy: bedtime, but not after 22h00.

However cheap super cialis 80 mg visa erectile dysfunction treatment options natural, the Calcium citrate does not require stomach acidity for subset analysis of only those patients who adhered to treat- absorption purchase super cialis 80mg without a prescription impotence mayo, and absorption is probably similar if taken with ment (those taking more than 80% of their supplements) meals. This suggests that the elderly may beneft from increased protein intake in addition to suffcient cal- Calcium Supplements cium, vitamin D, and physical activity. If calcium intake from meals is insuffcient and cannot be corrected, then calcium supplementation should be con- Potential Side-effects of Calcium Supplementation sidered. Lactose intolerant patients, vegans, chronic glu- Gastrointestinal Symptoms cocorticoid users, and those with a history of stomach sur- Gastrointestinal symptoms (bloating, gas, constipa- gery or malabsorptive bariatric procedures, celiac disease, tion) can be a problem in some patients. Adequate Evaluation for lactose intolerance, celiac disease, or lack vitamin D levels are also necessary to optimize absorption. Since these women citrate are the most common forms available, but other were permitted to use additional supplements on their forms may also be found, including lactate and gluconate. They are much more expensive and offer low calcium intake increases the risk of calcium oxalate no added health beneft. Calcium carbonate is about 40% kidney stones, probably due to binding of ingested calcium calcium. Calcium lactate is only 13% elemental by about 50% in patients receiving a normal calcium calcium, and calcium gluconate is 9% calcium. What Nutritional Recommendations are increased risk of kidney stones with calcium supplementa- Appropriate for Pregnancy and Lactation? Healthy eating in pregnancy and lactation has a sig- Prostate Cancer nifcant effect on both the mother and the child and can Prostate cancer risk was increased in 3,612 men fol- have a tremendous impact on their health, morbidity, and lowed prospectively who had an increased amount of dairy even mortality. Developing healthy eating behaviors requires active participation by the pregnant woman, as 4. Low levels of vitamin D result in decreased intestinal nutrition counseling and education. Meal plans including calcium absorption and cause secondary hyperparathyroid- optimal caloric intake and weight gain should be tailored ism and bone loss. Physicians should perform a thorough history and In addition to bone loss, vitamin D defciency has physical examination prior to conception. For example, the physical fnding of acanthosis cle tone and balance and reduces fall risk. Physicians should pay particular tation often delay diagnosis until 30- to 34-weeks gesta- attention to stopping any medications that could be poten- tion, well after the effects of hyperglycemia have begun to tially harmful to the fetus. Patient Education During Pregnancy A prenatal nutrition questionnaire helps the practitio- Pregnant women are more susceptible to food-borne ner to identify pregnancy-related problems affecting appe- illnesses and should practice safe food handling. Patients should also be queried on personal unpasteurized dairy products; thoroughly wash fresh pro- nutritional habits, including vegetarian, vegan, lactose-free duce before consuming it; and ensure that meats, poultry, and gluten-free diets, as well as cravings and aversions. All patients would beneft from referral to a dietician who Caffeine during pregnancy can increase the incidence specializes in nutrition in pregnancy and can evaluate the of miscarriage and stillbirth when consumed in large quan- patient’s individual habits, create an individualized meal tities. Generally, consuming less than 300 mg of caffeine plan, and address any special needs. Many women incorrectly estimate their daily weight gain for pregnant women who are obese. However, experts believe that it may be safe to gain little or no weight in pregnant women who are obese, additional calories may in this special population. Healthcare profes- Physical activity is also an important aspect of a sionals should determine the appropriate caloric intake for healthy pregnancy. Simple carbohydrates and Table 30 Dietary Reference Intakes for Womena,b Adult Lactation Nutrient woman Pregnancy (0-6 mo) Energy (kcal) 2,403 2,743 , 2,855c d 2,698 Protein (g/kg/day) 0. Protein is essential for the expansion Trans fatty acids may cross the placenta and may have of plasma volume; the generation of amniotic fuid; and to adverse effects on fetal development. Pregnant women who are vegetarian or Micronutrient Needs During Pregnancy vegan must be referred to a dietician specialized in preg- Pregnant women require specifc micronutrients to nancy to assist in specialized meal planning and recom- meet their gestational needs. Women should pay simplest way to assure that a woman is getting adequate close attention to the type of fat being consumed. Public Health Service recommends that all women in women are falling signifcantly short of recommended lev- their childbearing years consume 400 µg/day of folic acid. Women should be Women should maintain a daily iodine intake of 250 encouraged to eat 12 ounces of fsh per week. Maternal milk is also at the is needed for fetal erythropoiesis and an increase in mater- appropriate temperature, and breastfeeding creates a bond- nal red blood cell mass. Vitamin D requirements also do not change eral requirements all increase during lactation. Caloric intake exceeds prepregnancy demands by Vitamin A is imperative for fetal eye development and approximately 650 kcal/day in average sized women has been known to be defcient in developing countries. Anemic women on iron supplementa- lactation or eat a carbohydrate-containing snack prior to tion should take supplemental zinc.

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