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Topic Name: Pathophysiology – Burns
Student Name and ID
numbers :
Maryam Wasil A Jastaniah
U17104929
Section No.: 72
Instructor: Dr. Maha

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Topic: Burns
What is Burns ?
Burns are injuries initiated due to therma l, chemical, electrical, physical agents of
local and systemic repercussions or effects. Also, burns are considered to be one of
the most mortifying forms of traumatic injuries as it has caused so many victims to
suffer severely through the years.
Thermal burns are due to sources of heat that would significantly increase the
temperature of the skin causing damage of skin and cells.
Radiation burns are caused by being exposed to sources of radiation for a long
period of time such as sunlight and x -rays.
Chemical burns are caused by strong chemicals coming in contact with the skin or
eyes such as acids, detergents, alkali, etc.
Electrical burns , from its name is from electrical currents which could be direct or
alternating currents.

Classification of Burns
When classifying burns, the extent and depth of the burns are the most important
factors to be considered.
The extent of a burn is usually calculated by %TBSA (percentage of the Total Body
Surface Area) that has been burned. This could be done through sev eral methods
such as:
? Rule of Nines

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? Lund and Browder Chart
? Palmar Surface
The depth of a burn depends on how deeply and how severely a burn injury has
penetrated the skin’s surface. The burn depths are classified as degrees:
? First -degree Burns (superficial): affect epidermis or outer layer of
skin. Burn site is red in color, painful, dry and has no blisters. Could
be caused by mild sunburn where long term damage of the tissue is
rare.

? Second -degree Burns (partial thickness): affect epidermis and
part of the dermis layer of the skin. Burn site is red in color,
blistered, could be painful and appear to be swollen.

? Third -degree Burns (full thickness): the epidermis and dermis
are destroyed and could affec t the subcutaneous tissue, the burn
site may be white or charred.

? Fourth -degree Burns : damage the underlying bones, muscles, tendons and
destroy the nerve endings resulting in no sensation in the area.

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Assessment of Burns Using: Rule of Nines
Assessing a burn using the Rule of Nines is used to make the right treatment decisions
including fluid replacement or resuscitation – due to extreme fluid loss caused by
removal of the skin barrier on burn victims . The percentage of total body surface
area (%TBSA) that has been burned is estimated in multiples of nine.
The Rule of Nines is usually used in adults more than infants to assess second -degree
and third -degree burns as they are more severe and more traumatic than first -degree
burns. The percentage s are estimated based on different body areas:
? The Entire Head: 9%
? The Entire Trunk: 36%
? The Upper Extremity: 18%
? The Lower Extremity: 36%
? The Groin: 1%
(Note: each body area is divided into posterior – anterior OR right –left, depending
on the area. For example, the head = 4.5% anteriorly, 4.5% posteriorly.)
The factors that could slightly affect the Rule of Nines are the Body Max Index
(BMI) and age of the burn victim.

Effect of Burn Injury
Severe burn injuries tremendously effect the body. Burn victims usually go through
metabolic stress, meaning they become hyper metabolic and almost everything in
the body te nds to work faster. The blood pressure rapidly increases as well as the
heart rate, nutritional needs and pain – pain management becomes a priority.

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If the case is severe enough it could cause multiorgan failure where the heart could
shut down and the lun gs may be brutally affected. Along with that, these failures
could also lead to the victim’s kidneys to shut down and possibly infect the liver.
Extensive burns could also affect the immune system (generalized suppression).
Burn victims become more prone t o bacterial infections, this is due to depressed
complement levels and the reduction of neutrophil chemotaxis as well as
cytotoxicity.
Burns could cause both local and systemic responses : if the burn is less than 25% of
the total body surface are (TBSA) it causes a local response, if the burn is more than
25% of the total body surface area (TBSA) it produces both local and systemic
responses – considered more major injuries.
Still under the metabolic stress response, there is also an inflammatory hyper
catabolic response where there are higher levels of cytokines. These cytokine levels
elevate persistently and are directly related to age as well as the severity of the burn.
Major burn injuries could also effect :
? The Skeletal Muscles.
? The Bones.
So, the effects of burn injury on skeletal muscles include the turnover of muscle
protein, alteration of the protein metabolism and the mediators and of course the
functional impacts – muscle cachexia. These changes would t remendously impact
the locomotion and homeostasis of protein, lipids and glucose metabolism.
Muscle Protein Turnover in Burn Patients : The body proteins constantly synthesize
and break down resulting in a decrease of muscle mass also leading to an inadequate

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count of amino acids. This could cause organ failure as there may be a decrease in
blood circulation to specific organs.
Mediators of Altered Protein Metabolism Following Burns: Other th an the
breakdown of body proteins and amino acids, there are still factors such as the
resistance to insulin, the increase of stress hormones, an elevation of muscle wasting
after burn. Immobilization is also another factor, which is usually caused by the
several surgical procedures of more severe cases. Being bedridden or immobilized
postop increases the muscle deterioration or wasting.
Muscle Cachexia: A wasting syndrome where there is a significant loss in weight,
muscle (atrophy) and appetite. A burn su rvivor with this syndrome would face
fatigue, an increase in psychological distress, limitations of motion and self -care.
Effect of Burn on Bone: Severe burns cause an increase in bone resorption and
osteoclasts. There could also be a great chance of osteoporosis, significant decrease
in bone mass, etc.
There are so many effects all according to the severity of the burn, keep in mind that
burn survivors might not only be effected as an individual but the whole family or
caretaker would also be affected as they would have to provide assistance during
recovery.

Management of Burns
1. First Aid
2. Medical Management
3. Surgical Management

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The way you react and treat a burn during the first minutes after being injured can
really affect how severe the injury could get.
First Aid, immediate treatment:
Burn victims must “Stop, Drop & Roll” to put out any live flames and victims should
remove any burned clothing. If any clothing tends to stick to the skin DO NOT pull
on it, just cut around the burned area where it is adhered. Also any jewelry, tight
clothing or belts should be removed from burned areas and around the neck as the
skin starts to swell immediately after a burn.
Medical Management , treatment slightly differs depending on type of burn:
? First -degree Burns:
Apply or immerse in cool, fresh water until pain is reduced.
Cover the burn with sterilized – non -adhesive bandages or cloth.
Pain medication may be used to reduce pain and inflammation.
Seek medical attention only if the burn covers a very large area.

? Se cond -degree Burns:
For ten to fifteen minutes immerse area in fresh, cool water (dry & cover with clean
cloth, sterilized gauze).
DO NOT break blisters.
Take steps to prevent shock (lay flat, feet elevated approximately twelve inches,
covered with coat or blanket) – DO NOT take these steps if head, leg, back or neck
injury is suspected or even if it is just too discomforting.
Further medical treatment is a must.

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? Third -degree Burns:
Cover burn (with material that will not leave any lint residue on the burn) .
Take steps to prevent shock.
If the face is burned, the victim must sit up – beware of any breathing problems.
Burned area should be elevated above head if possible.
IMMEDIATE medical attention is required.

(In all types of burns do not use any ointment s or butter on the burns as it may cause
infection)

Surgical Management, Managing the Wound:
For any surgical intervention to succeed, the right operation must be done at the right
time. The two basic concepts that are used to manage a burn wound are: 1) Delayed
excision, and 2) Early excision. Depending on how severe the burn injury, it might
be required to apply both concepts but it is more common in most cases to use the
delayed excision.
After reconstructive surgery in severe cases, the patient may have to go through the
process of removing dead tissue. Then comes the plastic surgery intervention which,
according to the case, a treatment is chosen.
In plastic surgery several treatments are used, including:
? Skin Grafts : are the most common when treati ng burn patients, it is where skin
is removed from one are of the body and is transplanted and relocated where
needed.

? Microsurgery : during a burn incident, the patient may lose a finger, a toe, an
ear or even a lip in some cases. This treatment, these bo dy parts can be re –
attached and this surgery is usually used with the free flap procedure.

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? Free Flap Procedure : a procedure used during reconstruction where the
muscles, skin or the bones are transferred within the original blood supply (in
transplants).

? Tissue Expansion : this procedure is used to help the patient’s body kind of
“grow” extra skin, which could be needed in reconstruction surgery. The skin
is stretched by applying a balloon expander under or near the area in need of
repair. Th is causes the tissue to expand (stretch ; grow), then it is used to
basically reconstruct or correct the areas or body parts that were damaged
during the burn.

In conclusion, the techniques always vary according to the severity of the burn and
the age of the victim. Burns are very severe traumatic injuries which have the
possibility of affecting all ages. The steps to help a victim should be taken very
seriously to avoid worsening the patients status.

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References:
Efstathia Polychronopoulou, David N Herndon, Craig Porter; The Long -Term Impact of Severe Burn
Trauma on Musculoskeletal Health, Journal of Burn Care ; Research , Volume 39, Issue 6, 23
October 2018, Pages 869 –880, https://doi.org/10.1093/jbcr/iry035
https://www.arthroplastyjournal.org/article/S0950 -3501(97)80019 -0/pdf
https://www.webmd.com/skin -problems -and -treatments/plastic -surgery -burns#1
https://www.cdc.gov/masstrauma/factsheets/public/burns.pdf
https://www.omicsonline.org/open -access/burns -definition -classification -pathophysiology -and -initial –
approach -2327 -5146 -1000298.php?aid=93503
https://www.ncbi.nlm.nih.gov/books/NBK 430741/
https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90;ContentID=P09575
https://www.emedicinehealth.com/burn_percentage_in_adults_rule_of_nines/article_em.htm
https://www.verywellhealth.com/burn -pictures -4020409
https://www.ncbi.nlm.nih.gov/books/NBK513287/
https://www.hopkinsmedicine.org/healthlibrary/conditions/dermatology/burns_85,P01146
https://www.sharecare.com/health/burns/how -burns -affect -the -body
https://www.scribd.com/doc/36331191/Local -and -Systemic -Response -to-Burns

1.1 Overview
Learning to read and write is among the most important skills required for a child’s academic success at school as well as in his/her future education. Learning literacy skills will influence one’s performances in other disciplines. Literacy can have substantial impacts on developing livelihood. As claimed in a report by The World Bank (2002), people who had fulfilled literacy courses were shown to be more enthusiastic to improve their livelihoods. In addition to that, Eldred (2008) mentioned that literacy is associated with specific job skills as well as developments in critical thinking and problem solving. Similarly, Ekpo, Udosen, Afangideh, Ekukinam and Ikorok (2007) asserted that:
Over the years, there’s been a tremendous body of research conducted on the factors that affect literacy learning and development (Pretorius ; Mampuru,
2007). However, while researchers have come to an agreement about the different linguistic, socioeconomic, sociocultural and developmental elements in various contexts such as home, school and classroom which directly or indirectly influence the language and literacy achievements, a considerable debate about the best ways of teaching literacy to children continues to exist in the English- speaking countries (Harrison, 2004). In the past, as Chall (1983) put it, at the center of this great debate was the disagreement among those researchers, educators and policy makers who emphasized the bottom-up approaches (i.e. phonics) to literacy which focused on breaking the code and those who placed emphasis on whole-language (i.e. top-down) approaches in which meaning- emphasis was the center of attention.

In recent years, however, with the growth of convincing evidence from cognitive science which displays a strong relationship between success in literacy, phonemic/phonological awareness, and phonological skills (Anderson, 2004; Goswami; Bryant, 1990) and with the educational ministries of English-speaking countries seeking verification from ‘scientifically’ based research (Schemo, 2002), phonics has been adhered to as the best method of teaching literacy especially in primary stages.
1.2 Statement of the Problem
English as a foreign language is not the medium of communication in daily conversations and everyday life activities in Iran. Therefore, students’ exposure to English is only restricted to the English classroom and there do not have any chance of practicing English for learners outside the classroom setting.

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Iranian’s students start their formal English learning in the first grade of secondary school when they are about 12 or 13 years old. However, student’s English language learning has got importance for Iranian parents. Parents know the international place of English all over the world and the determining role that mastery of English holds in children’s educational future and job opportunities, many parents are willing to have their children start their English language learning as soon as possible. Hence, to attract registrations, lots of private primary schools and even kindergartens offer English language teaching in their curriculum. Nonetheless, because the government does not include English language teaching in primary levels, and thus is not among the main subject matters of primary school curriculum, English is placed at the last hours of school days as an extracurricular school course which also requires extra tuition from the parents. As a result, children who are already exhausted at these very last hours of the day at school do not take English seriously as a major school subject and this will result in a poor language attainment on the part of learners. In addition to these reasons, since English is usually considered just as a means of attracting customers in private primary schools, the quality of its teaching is not very desirable and satisfactory. Worse than that, the quality of formal English education in secondary school is very poor too. The textbooks which are written and presented under the supervision of Ministry of Education in Iran are based on very old methods of teaching English.

All in all, because of the overall disappointing conditions of English language teaching at schools and the late beginning of official English teaching in the Iranian educational system, parents resort to language institutes in the hope of giving their children the privilege of good English education. The quality of English teaching in language institutes is usually satisfactory compared to that of schools and the methods of teaching are often based on the ones offered by the new and popular textbooks such as Backpack (Herrera ; Pinkley, 2009), First Friends (Lannuzzi, 2011), Family and Friends (Simmons, 2010), etc. which have been written for ESL and EFL purposes by native authors. However, no systematic attention to learners’ literacy learning is observed in the language institutes in Iran. Phonics which has been identified as the best method of teaching literacy over the years (Beck, 2006) is used occasionally and from time to time rather than regularly and systematically. In other words, the method of teaching early literacy in most language institutes is the rote traditional phonics. Teachers start by teaching the letters of alphabet and their associated sounds followed by teaching some example words that start with those specific alphabet letters (e.g. apple is introduced as an example word for the letter sound a). This procedure is usually done through repeated drills in which the teacher chants the words and students repeat after the teacher in unison. As noted by Eshiet (2012), “This method lacks any form of motivation for the pupils as the knowledge gained through rote learning is not easily applicable when they see new words” (p. 3).

Due to the absence of Teacher Training Course (TTC) workshops to train teachers on how to teach phonics systematically, the teachers worsen the situation by their lack of competence in presenting systematic phonics to students and teaching English literacy appropriately. Therefore, the same as what Ekpo et al. (2007) describe, “The consequence is that some students just memorize some words without any clue to how those words are formed or pronounced. At the primary stages, words and short sentences are forced into the children’s memory through constant drill and memorizations”.

Ohiaeri (1994) and Ekpo (1999) have identified some obstacles to young learners’ ability to read at appropriate age in Nigeria, some of which are also true in Iranian EFL context:

1. High cost of books and lack of class readers by most pupils
2. Inadequate instructional time
3. Teachers are not prepare on reading at initial teacher training institutions
4. Adoption of poor teaching methods
5. Lack of appropriate variation in the teaching approaches to reading, for instance, the use of activities such as picture recognition, storytelling, card games, news reading, cartoon collection, posters, flash cards, role play, story club, reading competition, leisure reading, etc. can be incorporated into reading lessons for variety to generate interest (Edem, 2005).
6. Lack of commitment on the part of the teachers due to poor job satisfaction

As is clear from the factors enumerated by Ohiaeri (1994) and Ekpo (1999), the reason for the failure of most children in mastering English literacy is not because they are incapable to learn but to a great extent is because of the poor teaching methods adopted in teaching literacy. The teachers in schools and language institutes in Iran are required to thoroughly depend on and stick to the prescribed course materials offered by the relevant language institute or by the Ministry of Education in the case of secondary schools. Consequently, the learners are not provided with the right kinds of learning experiences which enable their appropriate mastery of literacy skills.

The irregularity of English writing system that is influenced by other languages adds fuel to this fire. For example, ch sounds sh in champagne which is the effect of French. Another instance is ch as in Christmas which sounds k and is the influence of Greek language. “Several centuries ago, the first dictionary was printed and once the words went into print, that’s how they were spelt. But pronunciation changes over the years and yet the link to the letters is not always the same” (Lloyd, 2012). The result is that there are only 26 letters but about 42 sounds in the English language and that’s what makes it more difficult to learn to read and write in English.

Jolly Phonics is a fun and child-centered approach to teaching literacy which has actions for each of the 42 letter sounds of English and teaches five key skills for reading and writing by using a synthetic multisensory approach. These five skills include (i) learning the letter sounds which consist of the alphabet sounds as well as diagraphs (e.g. sh, ai, etc.), (ii) learning letter formation, (iii) blending, (iv) segmenting, and (v) tricky words that have irregular spellings and children learn them separately in this method (“Teaching Literacy with Jolly Phonics”, 2014).
1.3 Purpose of the Study
Given the importance of literacy skills and the difficulties that young learners face with in reading and writing English at primary levels, this study aims at lighting upon a way to help children to learn reading and writing. To fulfill this objective, the present study seeks to discover the possible effects that the synthetic multisensory phonics (i.e. Jolly Phonics) can have on facilitating children’s early learning.
1.4 Significance of the Study
English, more than a century of debate has occurred over whether English phonics should or should not be used in teaching beginning reading. As a solution to overcome the above-mentioned barriers in the way of EFL/ESL children’s English literacy, the present study seeks to find out whether adopting a the synthetic method of Jolly Phonics is going to have significant impacts on helping young Iranian EFL learners to break through their reading and spelling difficulties. Despite the work of 19th century proponents such as Rebecca Smith Pollard, some American educators, prominently Horace Mann argued that phonics should not be taught at all. This led to the commonly used “look-say” approach ensconced in the “Dick and Jane” readers popular in the mid 20-th century.
Beginning in the 1950, however, phonics resurfaced as a method of teaching reading. Spurred by Rudolf Flesch’s criticism of the absence of phonics instruction (particularly in his popular book, why johnny can’t read, 1995) phonics resurfaced.
Spoken language is used in contexts that offer much support for meaning often from familiar and helpful adults who know the child and interact with him or her regularly. On the other hand, a child faced with a written text has support only from previous knowledge, from what the writer can build in, or through pictures or diagrams that illustrate the text. The writer is much more distant from a reader than is the case with speaking, and this distance can place a high demand on a reader to construct an understanding of the text (Reid, 1990 as cited in Cameron, 2001, p. 127).

As is maintained by Reid, it is clear that learning reading and writing skills are much more challenging for young learners than acquiring aural/oral skills. “Phonics teaching focuses on letter-sound (grapho-phonemic) relationships, building literacy skills from the bottom up. The usual way involves showing children the sounds of the different letters in the alphabet, then how letters can be combined. Phonics teaching works if it directs children’s attention to letter-sound level features of English and helps children make the mental connections between letters and sounds” (Cameron, 2001, p. 149). To achieve this, the present study seeks to apply a synthetic multisensory approach toward teaching phonics to the young learners and therefore offer them a helping hand in facilitating the troublesome task of learning literacy skills. Besides, phonics is usually regarded as “dry, boring and demotivating” (Cameron, 2001, p. 149). Therefore, Cameron (2001) suggests that phonics should be combined with fun activities which raise children’s interest such as songs and rhymes, and in stages of oral task. The present study may pave the ground to tackle these crucial issues, which have for long been neglected regarding the bore of phonics teaching, by adopting a fun synthetic multisensory approach to phonics which is believed to enhance learners’ motivation towards literacy learning.

1.5 Research Questions
Based on the purpose and the problem under focus in the present study, the following research questions are addressed:
1. Does the synthetic multisensory approach to phonics (i.e. Jolly phonics instruction) have any significant effect on Iranian young EFL learners’ reading skills?

2. Does the synthetic multisensory approach to phonics (i.e. Jolly phonics instruction) have any significant effect on Iranian young EFL learners’ spelling skills?

1.6 Null Hypotheses
Consequently, based on the aforementioned research questions the following hypotheses were formulated:

H1: The synthetic multisensory approach (Jolly Phonics method) adopted for teaching early literacy does not have any significant effect on the reading skills of Iranian EFL children.

H2: The synthetic multisensory approach (Jolly Phonics method) adopted for teaching English literacy does not have any significant effect on the spelling skills of Iranian EFL children.

1.7 Definition of the Key Terms
1.7.1. Phonics or Phonetic Method

According to Richards and Schmidth (2002), phonics is “a method of teaching children to read, in which children are taught to recognize the relationship between letters and sounds. They are taught the sounds which the letters of alphabet represent, and then try to build up the sound of a new or unfamiliar word by saying it one sound at a time” (p.398).

1.7.2. Multisensory Approach to Phonics

“Using a multisensory teaching approach means helping a child to learn through more than one of the senses” (Bradford, 2008 as cited in Ureno, 2012). According to Mohler (2002) he defines multisensory Approach to Phonics as follows: “Multisensory instruction received its name because all information was presented via sight, sound, voice, and kinesthetic means.

1.7.3. Synthetic Phonics

“The synthetic phonics method adopts the direct, systematic and rapid teaching of letter sounds to pupils. This is immediately followed by teaching them how to blend the letter sounds to form words. In English, pupils are taught the first group of letter sounds which make up a large number of 3-letter words; s, a, t, i, p, n. These sounds can be used to make several 3-letter words e.g. pin, sat, sit, tip, tin, pit, pat. The whole program is sometimes taught within a few months– usually
9 to 16 weeks with a great deal of emphasis on word reading. Sight words are taught at key points and carefully selected decodable readers are used alongside the program” (Eshiet, 2012, p. 6).

1.7.4. Jolly Phonics

“Jolly Phonics is a fun and child-centred approach to teaching literacy through synthetic phonics. With actions for each of the 42 letter sounds, the multi-sensory method is very motivating for children and teachers, who can see their students achieve” (“Teaching Literacy with Jolly Phonics”, December 2014).

1.7.5. Literacy

Richards and Schmidth (2002) define literacy as “The ability to read and write in a language” (p. 313).

1.7.6. EFL Young Learners
Mckay (2006) refers to young learners as follows: “Young language learners are those who are learning a foreign or second language and who are doing so during the first six or seven years of formal schooling. In the education systems of most countries, young learners are children who are in primary or elementary school. In terms of age, young learners are between the ages of approximately ?ve and twelve”. She further explains that “Young language learners may be foreign language learners, learning a language in a situation where the language is seldom heard outside the classroom. They may be learning languages like Vietnamese, Spanish or Chinese in Germany or the United States or they may be learning English as a foreign language (EFL) in countries like Turkey, Malaysia or Spain”.

1.8 Limitations and Delimitations of the Study
Like many other studies conducted in this area, the present one has suffered from a number of limitations which might jeopardize the generalizability of its findings. This study was implemented in a small language institute one of the limitations of this study, it was to some extent narrowed down in terms of the number of participants. Consequently, further research could take place with the inclusion of a larger number of participants within several larger schools or language institutes.

Furthermore, the participants of our study were 3-6 year-old students. Thus, the findings cannot be generalized to learners of other age groups. Subsequently, replicating the study with a group of other age group can be suggested.

 

Let’s imagine two trees are
growing near to each other. Trees compete for sunlight and nutrition from soil
but one of the trees is growing a little bit faster than the other. It absorbs
more sunlight and more nutrition, one the next day; the bigger tree will absorb
more sunlight and more nutrition and grow taller. And soon the taller tree will
cover the most part of the area and no area for a slow growing tree. The taller
tree will produce fruits fast and ultimately gives more and fast seeds. The next
generation of trees will grow even more faster and ultimately will cover the
whole forest.  It is called accumulative
advantage meaning the small advantage grows over time. How it is related to us
in real life? Let’s find out!

The winner gets everything

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The same
goes for people. We compete for the same money, respect, resources or everything
else. Such an effect, when a small difference in the return leads to a
disproportionate reward, is called the “Winner takes all”
effect. It is enough to have an advantage of only one percent, one second,
one dollar to get a 100% reward. 
Any decisions related to limited resources, such as time and money, naturally
lead to a situation where the winner receives everything.

Once you
start winning at the smallest level you start gaining advantages, it adds up
and it makes you successful again and again.

The winner gets the most

“Winner
gets everything” effect, characteristic for individual competitions, often
leads to the appearance of the “Winner gets the most” effect in other
areas of life. Having found himself in a profitable position (having won a gold
medal or having received a director’s chair), the winner begins to accumulate
advantages that help him win again and again. What was initially only a
small margin, now becomes more like a rule 20/80. 

Winning one
increases the chances of winning in the other. And each succeeding success
only strengthens the position of the winners. Over time, all the awards and
benefits are for those who at first slightly outperformed competitors and those
who have lagged behind remain almost with nothing. 

The small
difference in work with time can lead to an uneven distribution of
privileges. That’s why right habits are so important. 

It is enough to surpass competitors only by 1%. But if you maintain your
advantage today, tomorrow, day by day, you will win over and over again due to
this advantage. And every victory will bring all the best results. 

This is the rule of 1%. Do not need to be twice as good to get twice as
much. You need to put more effort into just 1%.

1.1. Background

Cerebral palsy is the neurological disorder and commonest cause of childhood physical disability. It affects movement and posture which are persistent but not necessary unchanging as a result of a defect or lesion that is not progressive in nature affecting the immature or growing brain (Rahman, 2015). When it is severe, results in marked difficulty with eating and drinking. Feeding problems occur early in life, often before other signs of a serious permanent movement disorder and during childhood nutrient intake will tend to be insufficient for energy requirements especially during periods of illness and growth spurt.
These aspects engender uncertainty and anxiety for mothers. The difficulty of movement control also means that the child will need help with other daily living skills and have great difficulty talking. There may also be other neurological problems such as epilepsy. All these features make eating and drinking more difficult. As most children with these difficulties live at home, the responsibility for providing their nourishment falls on mothers who often have little or no knowledge and expert support. It is therefore important that professionals understand mothers’ knowledge about nutrition of their child with CP (Sleigh, 2015).
Overall global prevalence rates of cerebral palsy (CP) are between 2 and 3 per 1,000 live births. Increased access to good healthcare services has reduced the prevalence of CP to 1.5 to 2.5 per 1,000 live births in developed countries. Trends are worse in poor resource countries such as sub?Saharan Africa where the prevalence is four times more than in developed countries (Mlinda, Leyna, ; Massawe, 2018).
The prevalence in USA is 2-2.5/1000 live birth, in Europe 2.08/1000(15), in China 1.6/1000(16). In Nigeria and Ethiopia 10/100,000 (17) and 20/100,000 population In Tanzania, the prevale(Rahman, 2015). prevalence of CP is unknown but it is estimated to be relatively much higher because of prevailing high perinatal morbidity(Mlinda et al., 2018). Other associated causes of cerebral palsy include birth asphyxia, birth trauma, and convulsion of unknown cause.
Childhood disability and poor nutritional status is often the commonest cause of early child mortality. Their nutritional status depends on proper nutritional awareness, knowledge, and complementary feeding practice by the mother (Mazumder, Rahman, Mollah, ; Haque, 2015; Rahman, 2015). Inability to self feeding and inability to request for food due to communication problems; result in feeding problems and poor nutritional status in children with CP (Rahman, 2015).
Poor motor skills also causes difficulties in manipulation of food once it is in the mouth placing children with CP at increased risk of aspiration and chocking/coughing while feeding which may further cause aversion of food, as well as inadequate nutritional intake. Lack of time and appropriate knowledge on special feeding needs of children with CP negatively impacts the child’s feeding. It also causes stress to caregiver and affects interaction with the child (Mlinda et al., 2018). Malnutrition is commonly considered as an important risk factor that can produce a negative influence on the prognosis of patients with Cerebral palsy (Mazumder et al., 2015).
Nutrition plays an important role in muscles growth and development, for children with cerebral palsy. These children require balanced diet as the normal children with respect to their age and body needs. Since they have difficulty feeding practices and low tendency to request food due to their disability, they need special attention from their mothers on nutrition. Knowledge of mothers on nutrition determines the nutritional status of their children with cerebral palsy.
1.2. Problem statement

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Malnutrition is currently big problem in children with cerebral palsy related disabilities in developing countries, failure to be addressed will results in poor prognosis of patients, child mortality, Parents denial, anger and blaming of the medical system for poor quality treatment, stigmatization/isolation of children in the family and community at large which has direct psychological effect on both parents and the child.
Poor knowledge of parents about nutrition of children with disability has increased the rate of malnutrition in sub-Saharan countries.
Cerebral palsy is the common worldwide neurological disorder, it’s the commonest cause of childhood physical disability (Rahman, 2015) Overall global prevalence rates of cerebral palsy (CP) are between 2 and 3 per 1,000 live births. Increased access to good healthcare services has reduced the prevalence of CP to 1.5 to 2.5 per 1,000 live births in developed countries. Trends are worse in poor resource countries such as in sub?Saharan Africa where the prevalence is four times more than in developed countries (Mlinda et al., 2018).
Knowledge of mothers about nutritional requirements of their children with cerebral palsy related disabilities is limited in developing countries like Tanzania, Nutrition and disability are intimately related, Both are global developmental priorities and elimination or prevention of malnutrition will improve health and well being of the children with disabilities (Mazumder et al., 2015).
As the prevalence of cerebral palsy is high in developing countries and mothers are primary caregivers of the children at home and health care facilities it’s important to conduct the study in Tanzania to rules out the level of knowledge of mothers about nutrition of their children in order to come out with concretes solution on preventing poor and negative prognosis of patients with cerebral palsy so as to improve their health and well being (Mlinda et al., 2018)
This study will improve feeding practices and nutritional status of children with cerebral palsy. Through knowing the level of knowledge about nutrition of the children we can come out with specific intervention like providing education to the mothers at the health care facility and home based education to enhance good feeding practices to the child with cerebral palsy to prevent malnourishment.
1.3. Research objectives
1.3.1 Broad objective
To assess the knowledge of mothers about nutrition of children with cerebral palsy in pediatric unit at MNH from November 2018 to March 2019.
1.3.2. Specific objectives
2. To evaluate the level of knowledge of mothers with respect to education level about nutrition of their children with cerebral palsy (CP) in pediatric unit at MNH.
3. To assess the nutritional status of cerebral palsy patient in pediatric unit at MNH.
1.4. Research questions
1. Is there a relationship between low weight (malnourishment) in children with cerebral palsy and levels of knowledge of their mothers about nutrition?
2. Is there any difference in levels of knowledge of mothers about nutrition of their child with respect to education level?
1.5. Research hypotheses
1. Children with cerebral palsy from mothers with high level of knowledge on nutrition of their children are less likely to be underweight compared to children with cerebral palsy from mothers with low level of knowledge on nutrition of their children
2. There is no any difference between levels of knowledge of mothers about nutrition of their children with respect to their education level.
1.6. Conceptual framework
The conceptual framework has been constructed with reference to different literatures and personal view that explain the factors related to knowledge of mothers about nutrition of their children with cerebral palsy also other studies explaining knowledge, altitudes and practices of mothers of children with cerebral palsy, and feeding practices of children with cerebral palsy has significantly contributed to the construction of this conceptual framework.
Education status of mothers has shown important association with the knowledge of mother, age of the mother also has association with knowledge about nutrition of children, information about nutrition received from health care workers and parenting practices also can be associated with level of knowledge of mother about nutrition of their children.

CHAPTER TWO: LITERATURE REVIEW

Cerebral palsy is the neurological disorder and commonest cause of childhood physical disability. It affects movement and posture which are persistent, but not necessary unchanging as a result of a defect or lesion that is not progressive in nature affecting the immature or growing brain (Rahman, 2015).
A study conducted in Bangladesh among the 100 children with cerebral palsy, 56% were boys and 44% were girls. Seventy seven percent of cases were underweight, while eighteen percent were within the normal weight and five percent were overweight. Majority of the respondents (seventy five percent) were currently giving only normal diet including soft/mashed foods like infant’s formula milk, dairy milk, rice, suji, infant’s formula cereals etc. except homemade energy density foods to their children, while 19% were given homemade energy density foods with complementary foods and the rest 6% were given only breast milk (Mazumder et al., 2015).
However, among low literacy mothers, 100% of the children were underweight whereas, it was 66% among high literacy mothers. Meanwhile, high literacy mothers had 18% normal weight child, but low literacy mothers had no normal weight child. Duncan Multiple Comparison Test (DMRT) showed that except class 1-9, all mothers who passed at least SSC level have same nutritional knowledge. However, knowledge about nutrition among mothers with CP is directly related with education (Mazumder et al., 2015).
A descriptive study conducted in Khartoum pediatric hospitals and Khartoum Cheshire Home for rehabilitation of disabled children. Two hundred and four children were enrolled in the study the mean age of the children was 46.06± (SD) 33.23 months. Among two hundred and four mothers half mothers 50.5% had good knowledge about CP and nutrition of their children and 49.5% of mothers had poor knowledge of CP and nutrition, 65% children belonging to mothers with good knowledge about CP and nutrition were malnourished and 98% of children from mothers with poor knowledge about CP and nutrition were malnourished (Rahman, 2015).
A study conducted in Taiwan to learn the experiences of mothers after learning their child diagnosis sowed that family members rejected the child, felt ashamed and that they had lost face due to the child’s disability, which further contributed to the mother’s hopelessness. Such rejection meant poor family support and failure to bond with the child. Some mothers felt that their parents-in-law thought they were not ‘good’ daughters-in-law, because they did not have a healthy baby. Such interactions prevented mothers from feeling a sense of identity, belonging and caring during this stressful time, leading to hopelessness and powerlessness in family relationships and this affected the level of mothers’ involvement in caring their children especially in nutrition requirement (Huang, Kellett, ; St John, 2015).
A study conducted at Muhimbili national hospital on the effect of a practical nutrition education programme on feeding skills of caregivers of children with cerebral palsy. There were two group intervention group and control group, in intervention group the mothers included were at least attended secondary school and the control group mothers had not attended to primary school. There were significant differences in feeding skills of caregivers in terms of better feeding positioning, slower feeding speed, better child support, and involvement during feeding. Caregiver-child interactions were also improved, where more caregivers of children in the intervention reported improved child mood and reduced caregiver stress during the feeding process than in control group (Mlinda et al., 2018)
Many studies concerning nutrition needs and feeding problems of children with cerebral palsy have been conducted in different parts of the world including Tanzania, but mothers knowledge about nutrition of their children were low therefore, assessing the knowledge of mothers about nutrition of children with cerebral palsy is an important issue since mothers are primary caregivers of the children. Then, there is a need to conduct the study in Tanzania in order to come out with important information on the knowledge of mothers about nutrition that will help in improving nutrition status of children with cerebral palsy.

References

Huang, Y. P., Kellett, U. M., ; St John, W. (2015). Cerebral palsy: Experiences of mothers after learning their child’s diagnosis. Journal of Advanced Nursing, 66(6), 1213–1221. https://doi.org/10.1111/j.1365-2648.2010.05270.x
Mazumder, S. I., Rahman, E., Mollah, A. H., & Haque, O. (2015). Knowledge about child nutrition among mothers of children with cerebral palsy. Asian Pacific Journal of Health Science, 2(1), 197–202.
Mlinda, S. J., Leyna, G. H., & Massawe, A. (2018). The effect of a practical nutrition education programme on feeding skills of caregivers of children with cerebral palsy at Muhimbili National Hospital, in Tanzania. Child: Care, Health and Development, 44(3), 452–461. https://doi.org/10.1111/cch.12553
Rahman, S. A. El. (2015). Knowledge, Attitude And Practice Of Mothers Of Children With Cerebral Palsy. Medical and Health Studies Board, 20(5), 98–106. Retrieved from http://khartoumspace.uofk.edu/handle/123456789/8400
Sleigh, G. (2015). Mothers’ voice: a qualitative study on feeding children with cerebral palsy. Child: Care, Health ; Development, 31(4), 373–383. https://doi.org/10.1111/j.1365-2214.2005.00521.x

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