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Birth to 24 months: Boys
Length-for-age and Weight-for-age percentiles
98
95
85
75
50
25
10
5
2
98
95
90
75
50
25
10
5
2
Published by the Centers for Disease Control and Prevention, November 1, 2009
SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en)
• Figure 1 (1) Birth to 24 months: boys’ length-for-age and weight-for-age percentiles. (2) Birth to
24 months: boys’ head circumference-for-age and weight-for-length percentiles. (Published by the
Centers for Disease Control and Prevention, November 1, 2009. From WHO Child Growth Standards.
Available at www.cdc.gov/growthcharts.) (3) 2 to 20 years old: boys’ stature-for-age and weight-for-age
percentiles. (4) 2 to 20 years old: boys’ body mass index-for-age percentiles. (From the National Center
for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health
Promotion, 2000.)
Birth to 24 months: Girls
Birth to 24 months: Girls Head circumference-for-age and NAME
Length-for-age and Weight-for-age percentiles Weight-for-length percentiles RECORD #
Birth
in cm cm in H
E
A
52 52
D
20 20
50 98 50 C
98 95 I
95 90 R
90 H 19 19
48 75 48 C
75 E U
50 50
A M
25 D 18 46 25 46 18 F
10 10 E
5 5 R
2 C 44 2 44 E
I 17 17 N
R C
C 42
24 E
U 52
16 23
M 40 50
F 22 48
E
15 38 21 46
98 R 98
E 95 20 44
95 N 36 90 42
14 19
90
C
E 75
18 40
34
50 38
75 13 17
36
32 25 16
10 34
50 15
12 5
30 2 32
14
25 30 W
28 13 28 E
10 I
5 26 12 12 26 G
2 11 11
24 24 H
22 10 10 22 T
20 9 9 20
18 8 8 18
16 7 7
16
W
E 14 14
6 6
I 12
14 12
G 5 5
10 kg lb
H 4 LENGTH
T 8
64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98100102104106108 110 cm
6 3
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 in
4 2
Date Age Weight Length Head Circ. Comment
2 1
lb kg
cm 46 48 50 52 54 56 58 60 62
in 18 19 20 21 22 23 24
Published by the Centers for Disease Control and Prevention, November 1, 2009 Published by the Centers for Disease Control and Prevention, November 1, 2009
SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en) SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en)
• Figure 2 (1) Birth to 24 months: girls’ length-for-age and weight-for-age percentiles. (2) Birth to
24 months: girls’ head circumference-for-age and weight-for-length percentiles. (Published by the Centers
for Disease Control and Prevention, November 1, 2009. From WHO Child Growth Standards. Available
at www.cdc.gov/growthcharts.) (3) 2 to 20 years old: girls’ stature-for-age and weight-for-age percentiles.
(4) 2 to 20 years old: girls’ body mass index-for-age percentiles. (From the National Center for Health
Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion,
2000.)
BOYS GIRLS
• Figure 3 (1) Birth to 18 years old: boys’ head circumference percentiles. (2) Birth to 18 years old: girls’
head circumference percentiles. (From Nellhaus G: Head circumference from birth to eighteen years.
Practical composite international and interracial graphs, Pediatrics 41:106–114, 1968.)
• Figure 4(1) Boys preterm infant (2) Girls preterm infant (From Fenton TR, Kim JH: A systematic review
and meta-analysis to revise the Fenton growth chart for preterm infants, BMC Pediatrics 13:59, 2013.)
Pediatric Primary Care
Sixth Edition
Editors
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permission in writing from the publisher. Details on how to seek permission, further information about the
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
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and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any
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Printed in China
Crisann Bowman-Harvey, CPNP, AC, PC, MSN Karen G. Duderstadt, PhD, RN, CPNP
Instructor Clinical Professor
University of Colorado Coordinator PNP Specialty
Aurora, Colorado Academic Coordinator of International Student Programs
and Special Studies
Donald L. Chi, DDS, PhD University of California San Francisco
Associate Professor School of Nursing
University of Washington, School of Dentistry, Department of Family Health Care Nursing
Department of Oral Health San Francisco, California
Seattle, Washington
Susan Filkins, MS, RD
Cynthia Marie Claytor, MSN, PNP, FNP Nutrition Consultant
Graduate Nursing Faculty Oregon Center for Children & Youth with Special Health
Azusa Pacific University Needs
Azusa California Oregon Health & Sciences University
Portland, Oregon
Sara D. DeGolier, RN, MS, CPNP
Pediatric Nurse Practitioner Leah G. Fitch, MSN, RN, CPNP
Department of Emergency Medicine Pediatric Nurse Practitioner
The Children’s Hospital Colorado and University of Providence Pediatrics, Carolinas HealthCare System
Colorado Denver Charlotte, North Carolina
Aurora, Colorado
iii
iv Contributors
Maxine Fookson, RN, MN, PNP Rita Marie John, EdD, DNP, CPNP, PMHS
Pediatric Nurse Practioner, School Based Health Program Associate Professor of Nursing at CUMC
Multnomah County Health Department PNP Program Director
Portland, Oregon Columbia University School of Nursing
New York, New York
Lauren Bell Gaylord, MSN, CPNP-PC
Pediatric Nurse Practitioner Veronica Kane, PhD, RN, MSN, CPNP
Etowah Pediatrics Clinical Assistant Professor, Coordinator—Pediatric
Rainbow City, Alabama Nursing Specialty
MGH Institute of Health Professions, School of Nursing
Teral Gerlt, MS, RN, WHCNP-E, PNP-R Boston, Massachusetts;
Instructor Pediatric Nurse Practioner, Pediatrics, Urgent Care
Oregon Health & Science University Harvard Vangard Medical Associates
School of Nursing Braintree, Massachusetts
Portland, Oregon
Julie Martchenke, RN, MSN, CPNP
Terea Giannetta, DNP, RN, CPNP, FAANP Pediatric Cardiology Nurse Practitioner
Associate Professor/Chief Nurse Practitioner Oregon Health & Science University
California State University, Fresno/Valley Children’s Portland, Oregon
Hospital
Fresno, California/Madera, California MiChelle McGarry, MSN, RN, CPNP, CUNP
Certified Pediatric and Urology Nurse Practitioner/
Denise A. Hall, BS, CMPE Program Director/Owner
Practice Administrator Pediatric Effective Elimination Program Clinic &
Advanced Pediatrics Associates Consulting, PC
Aurora, Colorado Highlands Ranch, Colorado
Ruth K. Rosenblum, DNP, RN, PNP-BC Elizabeth E. Willer, RN, MSN, CPNP
Assistant Professor, DNP Program Coordinator Pediatric Nurse Practitioner
San Jose State University Kaiser Permanente
San Jose, California Walnut Creek, California
Mary Rummell, MN, RN, CNS, CPNP, FAHA Teri Moser Woo, PhD, RN, ARNP, CNL, CPNP,
Clinical Nurse Specialist FAANP
The Knight Cardiovascular Institute, Cardiac Services Associate Professor
Oregon Health & Science University Associate Dean for Graduate Nursing Programs
Portland, Oregon Pacific Lutheran University
Tacoma, Washington
Susan K. Sanderson, DNP, APRN, FNP-BC
Pediatric Infectious Diseases Nurse Practitioner; Instructor Robert J. Yetman, MD
Department of Pediatrics Professor of Pediatrics
Division of Infectious Diseases Director, Division of Community and General Pediatrics
University of Utah School Of Medicine University of Texas–Houston Medical School
Salt Lake City, Utah UT Physicians Pediatrics—The Kid’s Place
Houston, Texas
Arlene Smaldone, PhD, CPNP, CDE
Associate Professor of Nursing at CUMC Yvonne K. Yousey, RN, CPNP, PhD
Associate Professor of Dental Behavioral Sciences (in Pediatric Nurse Practitioner
Dental Medicine) at CUMC Kids First Health Care
Assistant Dean, Scholarship and Research (School of Commerce City, Colorado
Nursing)
Columbia University
New York, New York
Reviewers
vi
Preface
We are delighted to introduce the sixth edition of Pediatric • NEW full-color design and illustration format to
Primary Care. This book was first developed 20 years ago improve usability and teaching/learning value
as a resource for advanced practice nurses serving the • NEW focus on diversity among cultures in Chapter 3
primary health care needs of infants, children, and adoles- provides greater emphasis on the need for providers to
cents. Pediatric nurse practitioners (PNPs) and family nurse approach differences between themselves and their clients
practitioners (FNPs) are our primary audience. However, with humility and competence
physicians, physician assistants, and nurses who care for • Reorganized application of Gordon’s Functional
children in a variety of settings also find the book to be a Health Patterns to provide a more conceptually consis-
valuable resource. The field of pediatric primary care has tent flow of content (Gordon, 1987, 2010)
also grown and changed since the first edition of this book. • Expanded coverage of health literacy—obtaining,
The interdisciplinary Institute of Medicine (IOM) and reading, understanding, and using health care informa-
the Affordable Care Act have explicitly recognized the criti- tion to make appropriate health decisions
cal role of nurse practitioners and nurses in providing • Expanded, updated coverage of growth and develop-
health care to the population in the United States (IOM ment for greater consistency with contemporary theories
Report, 2010). of development
The book emphasizes prevention and management of • Unique chapter on integrative/complementary thera-
problems from the primary care provider’s point of view. pies promotes the primary care provider’s knowledge
Each chapter is organized to introduce key concepts and about many of the less conventional health care strategies
foundations for care in a narrative format followed by a that families may be inquiring about or using
discussion of the identification and management of diagno- • Refocused Practice Management chapter (Chapter
ses using an outline format. Experienced clinicians can 44) is now available to readers on the Evolve website.
simply jump to the topic or diagnosis in question while the This chapter focuses on content more specific to pediat-
student can read the chapter for immersion into the topic. ric practice management, including the various settings
Additional resources for each chapter include websites to for pediatric primary care, such as school-based clinics
access organizations and printed materials that may be and the health care home. This refocused chapter also
useful for clinicians, their patients, and families. Our con- addresses informatics and other essential topics influ-
tributing authors are experts in their fields. enced by the Affordable Care Act, as well as National
Patient Safety Goals and the growing trend of interpro-
Special Features of the Sixth Edition fessional collaboration.
• Discussion questions and NEW PowerPoint slides are
Some features of the sixth edition about which we are par- available on the Evolve site for educators. These are
ticularly excited include the following: written by nurse practitioner educators to assist students
• Updated content reflects the latest developments in our to think about the implications of the material for their
understanding of disease processes, disease management clinical practice.
in children, and current trends in pediatric health care
• NEW Pediatric Pharmacology chapter Organization of the Book
• NEW Specialist Referral highlights to alert busy
practitioners to cues that signal the need for urgent We recognize that children are a special population and that
referral providing health care to them must be approached using
• NEW graduate-level Quality and Safety Education for several unique perspectives: their developmental changes
Nurses (QSEN) integration (Cronenwett et al, 2009): over time, their dependency on their parents, the differen-
The Safety, Informatics, Teamwork and Collaboration, tial epidemiology of child health, the different demographic
and Evidence–based competencies patterns of children and their families, and the individuality
vii
viii Preface
of their genetic makeup. These themes are carried through- Contributors to the Fifth Edition
out the text.
The book is organized into four major sections—Pediatric These people were instrumental in helping us develop the
Primary Care Foundations, Management of Develop- fifth edition of the book. Although they are not authors in
ment, Approaches to Health Management in Pediatric this edition, their ideas and work have contributed greatly
Primary Care, and Approaches to Disease Management. to our work, and we are deeply indebted to them: Barbara
Each chapter follows the same format. Standards and guide- Deloian, Mary Murphy, Maxine Fookson, Lynn Frost,
lines for care are highlighted, the physiologic and assess- Denise Abdoo, Roberta Bentson Royal, Veronica Kane,
ment parameters are discussed, management strategies are Martha K. Swartz, Anne Albers, Melissa Reider-Demer,
identified, and management of common problems is pre- Shirley Becton McKenzie, Peggy Vernon, Jan Bazner-
sented in a problem-oriented format. The scope of practice Chandler, and Constance Brehm.
of the primary care provider is always kept in mind with
appropriate referral and consultation points identified. Our Thanks to Family and Friends
We hope this text will continue to promote the very best
evidence-based care possible for children and families in • To my husband, Jerry Burns: Thanks so very much for
primary care settings by all the providers with whom they giving me the time and support to work on this text one
come in contact. more time; to my loving daughters Jennifer and Jill and
their families; other family and friends; and to the many
Editors PNPs, FNPs, and NP faculty who have expressed their
Catherine E. Burns, PhD, RN, CPNP-PC, FAAN appreciation for this text and encouraged us to continue
Ardys M. Dunn, PhD, RN, PNP the project. Catherine E. Burns
Margaret A. Brady, PhD, RN, CPNP-PC • To Marvin Dunn; Malcolm and Megan Dunn; Philip
Nancy Barber Starr, MS, APRN-BC (PNP), CPNP-PC Dunn and Liz Flynn, grandchildren Miles, Claire,
Catherine G. Blosser, MPA:HA, RN, PNP Simon, and Eleanor Dunn (from “the craziest Nana in
Dawn Lee Garzon, PhD, PNP-BC, CPNP-PC, PMHS, the whole wide world!”)—thanks for being my joy and
FAANP inspiration; and to so many other family and friends, you
are the spice of a well-flavored life. Ardys M. Dunn
Associate Editor • With deep appreciation for the circle of love and support
Nan M. Gaylord, PhD, RN, CPNP-PC from my dear family and friends who are always there
surrounding me with warmth, laughter, and joy. Marga-
References ret A. Brady
• Aloha and mahalo to my Jon, Jonah, and AnnaMei. I
Cronenwett L, Sherwood G, Pohl J, et al: Quality and safety educa- am ever grateful for the joy you bring to my life as well
tion for advanced nursing practice, Nurs Outlook 5(6):338–348, as your support of my time with “the book.” Likewise, I
2009. am ever thankful for Denise and my APA colleagues who
Gordon M: Nursing diagnosis: process and application, New York, give me the flexibility and challenge to work hand in
1987, McGraw-Hill.
hand to provide model pediatric care. Nancy Barber Starr
Gordon M: Manual of nursing diagnosis, ed 12, Sudbury, MA, 2010,
Jones and Bartlett.
• To my husband, Terry, for his continued love and support
Institute of Medicine (IOM) of the National Academies: The future and my admiration for all the littlest Blosser offspring
of nursing: leading change, advancing health, 2010. Available at: for their years of sharing their humor, strides, and
http://www.iom.edu/Reports/2010/The-Future-of-Nursing- challenges—they are amazing examples of the wonder of
Leading-Change-Advancing-Health (accessed October 28, 2014). growth and development. Catherine G. Blosser
• My thanks to the students, parents, and families who
Acknowledgments make me a better person; to Rachel and Elizabeth Garzon
who give my life meaning; and to Amy DiMaggio,
A book of this size and complexity cannot be completed friends, and family for loving me and giving me wings.
without considerable help—the work of the contributors Dawn Lee Garzon
who researched, wrote, and revised content; the consulta- • To my parents who first loved, supported, and encour-
tion and review of experts in various specialties who cri- aged me. To my husband, Mark, who loved me second
tiqued drafts and provided important perspectives and and continues to love, support, and encourage me in all
guidance; and the essential technical support from those my professional endeavors. To my children, Curtis and
who managed the production of the manuscript and the Leah, who make life fun and will continue to do so with
final product. Lee Henderson and Charlene Ketchum have their own children. Nan Gaylord
provided consistent Elsevier support through the past two
editions.
Contents
Unit 1: Pediatric Primary Care Foundations 16 Values, Beliefs, and Spirituality, 299
ix
x Contents
1
1
T
he health status of all children must be viewed with final section
a global lens. Whether considering pandemic infec available tc-> pcidiatric health care providers to assess and
tious diseases or the global emigration of popula monitor the health and well-being of children from infancy
tions between continents, the health of all children is to young aduldiood.
interconnected worldwide. Inequalities in the health status
of children globally and nationally are largely determined Global Health Status of Children
by common biosocial factors affecting health, which include
where they are born, live, are educated, their work, and their 'lliirty-five million children younger than 20 years old are
age (World Health Organization [WHO], 2014a). The bio r,art of the international migration of populations across
social factors also include the systems in place to address continents (UNICEF, 2014). Emigrant children have
health and illness in children and families. increased health and educational needs that impact the
The biosocial circumstances or social deter inants of health and well-being of communities; many of these com
child health are shaped by economics, soci polic,;ies, and munities have fragile health care systems. The United
politics in each region and country. In order to impact Nations Convention on the Rights of Children (UNCRC)
health outcomes, scaling up the efforts nationally and glob charter was established 25 years ago and declares the
ally to build better health systems is required. Significant minimum entitlements and freedoms for children globally,
progress has been made in reducing childhood morbidity including the right to the best possible health (United
and mortality using this approach. [he framework of the Nations International Children's Fund, 2009). Emigrant
United Nations Millennium Development Goals 2014 children have the right to be protected under this charter
(United Nations, 2015) and the Healthy People 2020 (U.S. (Box 1-1). Governments are advised to provide good quality
Department of Health and Human Services [HHS] Office health care, clean water, nutritious foods, and clean environ
of Disease Prevention and Health Promotion, 2015a) goals ments so that children can stay healthy. The charter is
set the mark for improving child health status. It is for founded on the principle of respect for the dignity and
societies to embrace and prioritize these goals on behalf of worth of each individual, regardless of race, color, gender,
children. language, religion, opinions, origins, wealth, birth status, or
This chapter presents an overview of the global health ability. The UNCRC continues to work on ensuring that
status of children, including the issue of global food inse all children have these basic human rights and freedoms.
curity, child health status in the United States and current Special emphasis is placed on the responsibility and strength
health inequalities, the progress toward achieving the Mil of families and the vital role of the international community
lennium Development Goals and Healthy People 2020 to protect and secure the rights of children, including access
targets, the effect of health care reform in the United States to health care and primary health care services.
on access to care for children and adolescents, and the Health equity is the absence of unfair or remediable dif
important role pediatric health care providers have in advo ferences in health services and health outcomes among
cating for polices that foster health equity and access to populations (WHO, 20146). Although the rate of child
quality health care services for all children and families. The mortality globally remains high, there have been significant
2
CHAPTER 1 Health Status of Children: Global and National Perspectives 3
• BOX 1-1 UNICEF* Summary of the United of reinfections for 2 to 3 months. As a micronutrient, it is
Nations Convention on the Rights of essential for protein supplementation, cell growth, immune
Children function, and intestinal transport of water and electrolytes
[Khan and Sellen, 2015].) Rotavirus is the most common
The UNICEF conventions include 42 articles that are cause of diarrhea globally and Streptococcus pneumoniae is
summarized in the following list. They represent the worldwide
the leading cause of pneumonia (Walker et al, 2013). Both
standards for the rights of children. The conventions apply to all
children younger than 18 years old. The best interests of of these are vaccine-preventable infectious diseases.
children must be a top priority in all actions concerning children. Successful vaccination programs have markedly reduced
• Every child has the right to: the mortality caused by some infectious diseases, particu-
• Life and best possible health larly measles and tetanus. Cambodia serves as a noteworthy
• Time for relaxation, play, and opportunities for a variety of
example. To reduce childhood mortality in children younger
cultural and artistic activities
• A legally registered name and nationality than 5 years old, Cambodia targeted measles vaccination
• Knowledge of and care by his or her parents, as far as due to the high mortality associated with the disease. Within
possible, and prompt efforts to restore the child-parent a decade, health workers were able to increase the rate of
relationship if they have been separated measles immunization by 71% in children younger than
• Protection from dangerous work
1 year old (United Nations, 2015). To achieve complete
• Protection from use of dangerous drugs
• Protection from sale and social abuse, exploitation, eradication of measles, WHO helped the Cambodian
physical and sexual abuse, neglect and special care to national immunization program to identify and reach
help them recover their health if they have experienced communities at high risk for low rates of immunizations.
such toxic life events A national immunization program also began providing
• No incarceration with adults and opportunities to maintain
a booster dose of a measles-containing vaccine after
contact with parents
• Care with respect for religion, culture, and language if not 18 months old. The result was measles eradication in
provided by the parents Cambodia since 2012. Such sustained immunization pro-
• A full and decent life in conditions that promote dignity, grams by partnerships between communities, governments,
independence, and an active role in the community, even and international aid organizations can markedly improve
if disabled
global child health status. However, emerging viral and
• Access to reliable information from mass media,
television, radio, newspapers, as well as protection from bacterial infectious diseases present complex challenges to
information that might harm them public health infrastructure and threaten the global progress
• Governments must do all that they can to fulfill the rights of made on reducing childhood mortality (see Chapter 24).
children as listed above. The majority of the extremely poor live in five
*UNICEF stands for the full name United Nations International Children’s countries—India, China, Nigeria, Bangladesh, and the
Emergency Fund. In 1953, its name was shortened to the United Nations Democratic Republic of Congo. The risk of maternal death
Children’s Fund. However, the original acronym was retained.
from pregnancy-related complications and childbirth in
developing regions is 230 deaths per 100,000 births; this
rate is 14 times higher than in developed countries (United
Nations, 2015).
reductions in the rate over the past few decades. Since 1990,
child mortality in children younger than 5 years old has
decreased by 47% due to targeted policies to reduce child- Global Food Insecurity and Effect on
hood pneumonia, diarrhea, and malaria and also to reduce Children’s Health
the number of preterm births and perinatal complications.
Despite these efforts, 6.3 million children younger than 5 Hunger and undernutrition are often referred to as food
years old die each year worldwide (Wang et al, 2014). To insecurity, which is the condition that exists when popula-
reach the World Health Organization (WHO) target of tions do not have physical and economic access to sufficient,
two-thirds reduction in mortality for children younger than safe, nutritious, and culturally acceptable food to meet
5 years old, more rapid progress is needed, particularly in nutritional needs. Food insecurity occurs in impoverished
sub-Saharan Africa, where the highest rate of infant mortal- populations in developing countries and in industrialized
ity occurs. Currently, sub-Saharan Africa and Southern Asia nations, particularly among migrant populations. Children
account for 81% of the infant mortality globally (United affected by migration and family separation are at risk for
Nations, 2015). food insecurity and are vulnerable to further health conse-
Diarrhea and pneumonia remain the leading infectious quences, including exposure to exploitation and child traf-
causes of childhood morbidity and mortality globally. The ficking. Growing evidence on climate change indicates the
highest proportion of deaths due to these two conditions is dramatic effect on food crops that lead to food distribution
in children younger than 2 years old; undernutrition, sub- issues, which is one of the primary contributors to food
optimum breastfeeding, and zinc deficiency contribute sig- insecurity (Fig. 1-1).
nificantly to the mortality rate from these diseases. (Zinc Globally, undernutrition is an important determinant of
reduces the duration and severity of diarrhea and likelihood maternal and child health and accounts for 45% of all child
4 UNIT 1 Pediatric Primary Care Foundations
Health effects
Temperature-related
illness and death
Regional weather
changes
• Contamination
pathway
Air pollution-related
health effects
• Transmission
Climate
• Heatwaves dynamics Water- and food-borne
change • Extreme weather • Food diseases
• Temperature availability
• Precipitation • Migration Vector- and rodent-borne
diseases
Psychological effects
Adaptation
measures Malnutrition
Research
deaths in children younger than 5 years old (United Nations, One of the main goals of the Millennium Development
2015). Suboptimal breastfeeding remains a problem in Goals framework is to reduce infant mortality by at least
developed and developing nations. Children who are exclu- two-thirds by 2016 in 27 countries. Eight goals consist of
sively breastfed for the first 6 months of life are 14 times 21 quantifiable targets measured by 60 health indicators
more likely to survive than non-breastfed infants (United (see Fig. 1-3). They provide a framework for the interna-
Nations, 2015). Vitamin A and zinc deficiencies also con- tional community to ensure socioeconomic development
tribute to the disease burden in mortality for children reaches all children.
younger than 5 years old. In developing countries, 55
million women are stunted from undernutrition and lack Progress on the Millennium
of micronutrients, including iron, folic acid, vitamin A, and Development Goals
zinc (Save the Children, 2015). Preventable nutritional defi-
ciencies are a compelling case for further implementation Significant progress has been made in many areas, including
of the Millennium Development Goals and increased reductions in child mortality and preterm birth. In 30
support for micronutrient supplementation for children in developing countries, progress toward achieving reductions
developing regions. in child mortality has been faster than predicted due to
income, education, and secular shifts in living and work
environments (Wang et al, 2014). However, increased assis-
United Nations Millennium Development tance in improving economic status and levels of maternal
Goals: Project Goals education is required to sustain the effort.
Since 1990, progress has been made by reducing world
The Millennium Project, a global health project of research poverty by half, access to clean drinking water has improved
and study to improve prospects for a better future for for 2.3 billion people, chronic undernutrition in children
humanity, publishes a framework (Millennium Develop- causing stunting has decreased by 40%, and 90% of chil-
ment Goals) annually to address the challenges, both local dren in developing regions are attending primary school
and global, facing the world populations. Health and access (United Nations, 2015). The achievements are the result of
to health care in the context of social determinants are the collaborations between governments, international
covered in the document. Figures 1-2 and 1-3 and Box 1-2 communities, civil societies, and private corporations. To
illustrate the collaborative action required among govern- make further sustained progress, expansion and acceleration
ments, international organizations, corporations, universi- of the interventions by the WHO are required to target the
ties, and individuals and societies to address the issue of leading causes of death in the target countries.
health equity from a global perspective (The Millennium The economic growth potential remains strong in
Project, 2014). many of the developing regions, and partnerships between
CHAPTER 1 Health Status of Children: Global and National Perspectives 5
Sustainable development
and climate change
Energy 13 Democratization
4
10 7 Rich–poor gap
Peace and conflict
9 8
Education Health issues
• Figure 1-2 Fifteen global challenges facing humanity. IT, Information technology.
Title: Nick Carter Stories No. 120, December 26, 1914: An uncanny
revenge; or, Nick Carter and the mind murderer
Language: English
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No. 120. NEW YORK, December 26, 1914. Price Five
Cents.
AN UNCANNY REVENGE;
ESCAPE BY SCHEDULE.
Nick was led through a couple of sumptuously furnished rooms into the
great Swedish actress’ presence.
Helga Lund was a magnificently proportioned woman, well above
medium height, and about thirty years of age.
She wore a loose, filmy negligee of silk and lace, and its pale blue was
singularly becoming to her fair skin and golden hair. Two thick, heavy ropes
of the latter hung down far below her waist.
She was not merely pretty, but something infinitely better—she had the
rugged statuesque beauty of a goddess in face and form.
She was pacing the floor like a caged lioness when Nick entered. Her
head was thrown back and her hands were clasped across her forehead,
allowing the full sleeves to fall away from her perfectly formed, milk-white
arms.
“Miss Lund, this is Mr. Carter, of whom I spoke,” Doctor Lightfoot said
gently. “He believes he can help you. “I shall leave you with him, but I will
be within call.”
He withdrew softly and closed the door. They were alone.
The actress turned for the first time, and a pang shot through the tender-
hearted detective as he saw the tortured expression of her face.
She nodded absent-mindedly, but did not speak.
“Miss Lund,” the detective began, “I trust you will believe that I would
not have intruded at this time if I hadn’t believed that I might possibly
possess the key to last night’s unfortunate occurrence, and that——”
“You—the key? Impossible, sir?” the actress interrupted, in the precise
but rather labored English which she had acquired in a surprisingly short
time in anticipation of her American tour.
“We shall soon be able to tell,” Nick replied. “If I am wrong, I assure you
that I shall not trouble you any further. If I am right, however, I hope to be
able to help you. In any case, you may take it for granted that I am not trying
to pry into your affairs. I have seen you on the stage more than once, both
here and abroad. It is needless to say that I have the greatest admiration for
your genius. Beyond that I know nothing about you, except what I have
read.”
“Then, will you explain—briefly? You see that I am in no condition to
talk.”
“I see that talking, of the right kind, would be the best thing for you, if the
floodgates could be opened, Miss Lund,” Nick answered sympathetically. “I
shall do better than explain; with your permission, I shall ask you a
question.”
“What is it?”
“Simply this: Are you acquainted with a New York surgeon who goes by
the name of Doctor Grantley—Hiram A. Grantley?”
The actress, who had remained standing, started slightly at the detective’s
words. Her bosom rose and fell tumultuously, and her clenched hands were
raised to it, as Ida Jones had described them.
A look of mingled amazement and fright overspread her face.
Nick did not wait for her to reply, nor did he tell her that it was
unnecessary. Nevertheless, he had already received his answer and it gave
him the greatest satisfaction.
He was on the right track.
“Before you reply, let me say this,” he went on quickly, in order to
convince her that she had nothing to fear from him: “Grantley is one of the
worst criminals living, and it is solely because our laws are still inadequate
in certain ways that he is alive to-day. As it is, he is a fugitive, an escaped
prisoner, with a long term still to serve. He escaped last night, but he will
undoubtedly be caught soon, despite his undeniable cleverness, and returned
to the cell which awaits him. Now you may answer, if you please.”
He was, of course, unaware of the extent of Helga Lund’s knowledge of
Grantley. It might not be news to her, but he wished—in view of the actress’
evident fear of Grantley—to prove to her that he himself could not possibly
be there in the surgeon’s interest.
His purpose seemed to have been gained. Unless he was greatly mistaken,
a distinct relief mingled with the surprise which was stamped on Helga’s
face.
“He is a—criminal, you say?” she breathed eagerly, leaning forward,
forgetful that she had not admitted any knowledge of Grantley at all.
“You do not know what has happened to Doctor Grantley here in the last
year?”
“No,” was the reply. “I have never been in America before, and I have
never even acted in England. I do not read the papers in English.”
“You met Grantley abroad, then, some years ago, perhaps?”
The actress realized that she had committed herself. She delayed for some
time before she replied, and when she did, it was with a graceful gesture of
surrender.
“I will tell you all there is to tell, Mr. Carter,” she said, “if you will give
me your word as a gentleman that the facts will not be communicated to the
newspapers until I give you permission. Will you? I think I have guessed
your profession, but I am sure I have correctly gauged your honor.”
“I promise you that no word will find its way, prematurely, into print
through me,” Nick declared readily. “I am a detective, as you seem to have
surmised, Miss Lund. I called on you, primarily, to get a clew to the
whereabouts of Doctor Grantley, but, as I told you, I am confident that it will
have a beneficial effect on you to relieve your mind and to be assured, in
return, that Grantley is a marked and hunted man, and that every effort will
be made to prevent him from molesting you any further.”
“Thank you, Mr. Carter,” the actress responded, throwing herself down
on a couch and tucking her feet under her.
The act suggested that her mental tension was already lessened to a
considerable degree.
“There is very little to tell,” she went on, after a slight pause, “and I
should certainly have confided in my physicians if I had seen any use in
doing so. It is nothing I need be ashamed of, I assure you. I did meet Doctor
Grantley—to my sorrow—five years ago, in Paris. He was touring Europe at
the time, and I was playing in the French capital. He was introduced to me as
a distinguished American surgeon, and at first I found him decidedly
interesting, despite—or, perhaps, because of—his eccentricities. Almost at
once, however, he began to pay violent court to me. He was much older than
I, and I could not think of him as a husband without a shudder. With all his
brilliancy, there was something sinister and cruel about him, even then. I
tried to dismiss him as gently as I knew how, but he would not admit defeat.