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Conference on Malnutrition matters
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1 , Page 1 of 7 doi: /s g The Author 2009 The Annual Meeting of the Nutrition Society and BAPEN was held at Harrogate International Centre, Harrogate on 4 5 November 2008 Conference on Malnutrition matters Symposium 5: Joint BAPEN and Nutrition Society Symposium on Feeding size 0: the science of starvation Severe malnutrition: therapeutic challenges and treatment of hypovolaemic shock Kathryn Maitland KEMRI-Wellcome Trust Programme, PO Box 230, Kilifi, Kenya The systematic failure to recognise and appropriately treat children with severe malnutrition has been attributed to the elevated case-fatality rates, often as high as 50%, that still prevail in many hospitals in Africa. Children admitted to Kilifi District Hospital, on the coast of Kenya, with severe malnutrition frequently have life-threatening features and complications, many of which are not adequately identified or treated by WHO guidelines. Four main areas have been identified for research: early identification and better supportive care of sepsis; evidence-based fluid management strategies; improved antimicrobial treatment; rational use of nutritional strategies. The present paper focuses on the identification of children with sepsis and on fluid management strategies. Severe malnutrition: African children: Identification of sepsis: Fluid management strategies The WHO consider that a mortality rate of >20% for children with severe malnutrition, a situation that is common in many hospitals in sub-saharan Africa, is unacceptable (1 5). High case-fatality rates are often attributed to insufficient staff training and poor compliance with the recommended protocols (6 12). The WHO has developed consensus management guidelines (2) that include a stabilisation phase during which life-threatening problems are identified and treated, a staged introduction of milk-based nutritional rehabilitation, micronutrient and vitamin supplementation and empirical use of antimicrobial and antihelminth treatments. It is argued that with strict adherence to these guidelines the mortality should be <5% (13,14). Whilst high case-fatality rates are often attributed to faulty case management, the evidence for this assertion is poor and other workers have suggested that outcome is largely dependent on other antecedent factors, including the frequency of additional life-threatening complications (4,15 18). The current guidelines have largely been based on expert or consensus opinion. Consequently, there are several aspects that are controversial (3,15). A major challenge is that they have been developed to be relevant to many varying contexts and geographic settings that include: diverse populations such as those exposed to displacement (refugees) where acute starvation in previously healthy populations may be compounded by diarrhoea in unsanitary settings (19) ; acute malnutrition secondary to epidemics of cholera, dysentery (13) or measles; cases admitted from populations with stable endemic undernutrition. In the latter situation, because of the high rates of comorbidity, successful treatment may not be guaranteed by strict compliance with current management guidelines alone. At Kilifi District Hospital, on the coast of Kenya, severe malnutrition is a common cause of admission; paediatric cases are treated annually. The current management approaches the gold standard recommended by the WHO (2). However, in-hospital mortality remains at approximately 20% (17) and has been stable over time despite in-service training and expansion of the dedicated nutrition team. More careful adherence to WHO recommended Abbreviations: ORS, oral rehydration solution; ReSoMal, rehydration solution for malnutrition. Corresponding author: Dr Kathryn Maitland, fax ,
2 2 K. Maitland management (6,9) could be achieved by a considerable investment in health personnel, but without a careful reexamination of current management recommendations this approach is unlikely to impact substantially on the outcome for those at greatest risk of dying. Every cohort of children with severe malnutrition will comprise subgroups with different antecedent risk factors. It is recognised that in Kilifi District Hospital the largest group comprises children with uncomplicated malnutrition who have accessed hospital care for nutritional rehabilitation alone. For these children the management and inpatient survival approaches the standard recommended by the WHO guidelines (2). Nevertheless, a substantial group of children present to hospital with severe illness and lifethreatening complications. An acute medical or nutritional decompensation, and more often the combination, underpin their hospitalisation and represent a major challenge to successful management. At Kilifi District Hospital a prospective study of children with severe malnutrition has been conducted over the last decade, which has identified a number of areas of concern in relation to management; early mortality being of particular concern, as >40% of deaths have been found to occur within 72 h of admission (17). This finding suggests that triage, early identification and adequate treatment of life-threatening complications are inadequate and need more careful scrutiny. Factors contributing to poor outcome A retrospective review, conducted in 2006, has identified a number of important factors that contribute to poor outcome and highlights the therapeutic challenges encountered (17), which include: (1) invasive bacterial infection: bacteraemia was found to complicate 27% of all deaths; 52% dying before 48 h, despite 85% in vitro antibiotic susceptibility of cultured organisms; (2) early deaths were frequently found to be complicated by features of hypovolaemic shock or dehydrating diarrhoea at admission; (3) very few children were identified as shocked or requiring intravenous fluids because of the very stringent criteria for fluid resuscitation specified in the WHO guideline (2). (4) high mortality was found for those patients with severe dehydration and severe electrolyte derangements; (5) more than one life-threatening complication was frequently found to complicate the hospital admission. Furthermore, on review it was found that the WHO danger signs (2) lack the sensitivity and specificity to identify those patients at greatest risk of early mortality. In 2005 the Kilifi Severe Malnutrition Research Programme was established in order to systematically evaluate the current WHO management guidelines (2). A major programmatic theme is to identify areas that require further research with the aim of providing a broader evidence base for future recommendations. Gastroenteritis and dehydrating diarrhoea Profuse watery diarrhoea, defined as three or more loose stools per d, often complicates severe malnutrition (20). Management of diarrhoea and dehydration continues to be a controversial issue in the treatment of severe malnutrition. The difficulty of differentiating the signs of acute dehydration from chronic features of malnutrition has been recognised but poorly evaluated physiologically (2). Some studies have shown that the presence of diarrhoea predicts poor outcome (4,17,21), especially when complicated by other features of severity, whereas other studies have shown little impact on successful rehabilitation (13). It has been shown previously that both community- and nosocomialacquired diarrhoea are major challenges to the successful management of Kenyan children hospitalised with severe malnutrition, with the highest mortality occurring in the groups with clinical signs of severe dehydration and impaired perfusion (17). WHO recommended management Diarrhoea and dehydration at Kilifi District Hospital are managed in accordance with WHO policy (2). In brief, this procedure includes the provision of an oral rehydration solution (ORS) with a reduced Na content (rehydration solution for malnutrition; ReSoMal; for details, see World Health Organization (2) ), micronutrient and vitamin supplementation, antibiotics and starter F75 milk-based feeds (for details, see World Health Organization (2) ). ReSoMal is provided on the ward following initial observed rehydration and carers are encouraged to give additional ReSoMal for every loose stool. For children too weak or unable to rehydrate orally a nasogastric tube is inserted for enteral rehydration and feeding. Intravenous rehydration is reserved for children developing advanced shock, as stipulated in the WHO guideline (2), which is defined as impaired consciousness together with capillary refill >3 s, a weak pulse volume and a temperature gradient (cool hands and feet). The results of the 2-year prospective study (June 2005 May 2007) include 667 children with severe malnutrition (10% of all hospital admissions). A total of 325 children (49%) were admitted with a history of diarrhoea, of which seventy-seven (24%) died compared with 14% of the 342 cases that were uncomplicated by diarrhoea (c , P<0. 001). Table 1 demonstrates the admission characteristics for the 325 children with severe malnutrition complicated by diarrhoea. Of note is the poor performance of the WHO danger signs (2) to identify those children at risk of dying and the limited number that would qualify for intravenous rehydration. Despite severe biochemical derangement and other features of shock only one child of the 325 with a history of diarrhoea was found to be eligible for intravenous fluid rehydration at admission. Fatal cases were more frequently found to be complicated by clinical evidence of dehydration or impaired perfusion, severe acidosis or electrolyte imbalance and invasive bacterial infection. Notably, HIV status was not found to be a predictor of poor outcome. A further ninety-eight children were found to develop diarrhoea after admission ( nosocomial diarrhoea ), of whom twenty-one died (21%).
3 Severe malnutrition: therapeutic challenges 3 Table 1. Admission features of 325 children with severe malnutrition complicated by diarrhea Feature Cases with feature n % WHO treatment indicators (2) Shock definition Danger signs (lethargy, hypothermia or hypoglycaemia) Bedside assessment Severe dehydration signs Capillary refill >2 s 27 8 Weak pulse volume 32 8 Any impairment of consciousness 16 4 Laboratory Acidosis (base deficit >10 mmol/l) Hyponatremia, ( < 125 mmol/l) 29 8 Hypokalaemia, (<2. 5 mmol/l) Elevated creatinine, ( >80 mmol/l) Bacteraemia (admission culture) 28 8 It was noted that in both groups a number of children developed profuse osmotic diarrhoea. This condition led to a rapid collapse (often within hours of the development of severe diarrhoea) with features of haemodynamic decompensation, severe electrolyte abnormalities, metabolic acidosis and ultimately death. Osmotic diarrhoea has been reported before in Aboriginal communities with a tropical enteropathy (with similar complications on feeding) (16,22) and these previous observations have parallels with the findings at Kilifi District Hospital. Therapeutic challenges: intravenous rehydration In children without anthropometric or clinical signs of malnutrition any one of these complications would ordinarily prompt urgent intravenous fluid resuscitation and rehydration. Under the current WHO guidelines (2) intravenous fluid resuscitation is reserved for too few cases with signs of advanced shock, when it is probably too late and thus fluid resuscitation is often associated with high mortality. Similar observations have been reported, with advice for the targeted use of isotonic fluids in those patients with any feature of shock (16). Therapeutic challenges: oral rehydration The use of the standard WHO ORS (2,13) with 90 mmol Na/l for severely-malnourished children has been cautioned because of its relatively high concentration of Na and low K concentration (Table 2). As a result of the adaptive state of severe malnutrition there is a concern that ORS containing large quantities of Na may result in further increases in intracellular Na and the risk of fluid overload and heart failure (20,23). In a randomised trial of Bangladeshi children with severe malnutrition in which the efficacy and safety of ReSoMal was compared with that of the standard WHO ORS similar efficacy was demonstrated for correcting dehydration, but ReSoMal was found to be associated with a more beneficial effect on K status, with most Table 2. Standard composition (mmol/l) of oral rehydration solutions (ORS) Standard WHO ORS (2) ReSoMal (2) Reduced-osmolarity ORS New WHO reduced osmolarity ORS (25,26) Diorolyte Glucose Na Chloride K Citate Osmolarity ReSoMal, rehydration solution for malnutrition. children correcting hypokalaemia by 24 h. However, hyponatraemia was reported to persist in 25% of the children treated with ReSoMal, which was complicated by the development of seizures (23). The interpretation of the study findings may be complicated by the presence of Vibrio cholera in 30% of the study population. Nevertheless, ReSoMal has subsequently been adopted into the present guideline as the standard ORS for children with severe malnutrition (2). Since this trial the WHO has changed the formulation for ORS for non-malnourished children (24,25) (see Table 2). For a number of reasons, including the potential safety concerns of ReSoMal together with the author s observations that mortality remains high on current management and the introduction of an ORS with lower Na content and higher K, prospective evaluation is warranted in comparing ReSoMal against the new standard WHO ORS. Ultimately, there are programmatic and logistic advantages to using a single solution around the world for all causes of diarrhoea in all ages irrespective of nutritional status. Treatment of hypovolaemic shock: phase I and II clinical trials WHO guidance on fluid resuscitation Current WHO guidelines recommend that children with severe malnutrition should not routinely receive intravenous fluids (2). Fluid resuscitation should be reserved for those with signs of decompensated shock (cool peripheries, capillary refill time >3 s, a rapid and weak pulse and impaired consciousness). In this situation treatment guidelines recommend an initial bolus of half-strength Ringers lactate, half-strength Darrow s solution or 0. 45% (w/v) saline followed by whole-blood transfusion if the child fails to improve (2,20). Are the guidelines evidence based? The recommendations for children with severe malnutrition are based on two largely unproven concerns. First, in simple terms, children with severe malnutrition retain Na (and water) and therefore infusions of Na-rich crystalloidal solutions may be detrimental, leading to salt and
4 4 K. Maitland water overload. Second, children with severe malnutrition have impaired cardiac function and incipient heart failure. These rationale have been advanced to discourage the use of isotonic or Na-rich resuscitation fluids or ORS. Limitations of treatment guidelines Although hypotonic solutions may correct intracellular volume depletion (dehydration), the crystalloid solutions recommended by the current guidelines for correction of shock in severe malnutrition (2) are not recognised in contemporary paediatric critical care practice. Paradoxically, hypotonic fluids represent a much greater risk of fluid overload because of rapid equilibration of water across the extracellular and intracellular compartments, following the osmotic gradient, leading to a proportionately greater expansion of the intracellular compartment relative to the intravascular compartment. Hence, they have a limited effect on expanding the circulating volume or correction of shock. Furthermore, the recommendation for using blood as a volume expander is physiologically unsound and overlooks the literature relating to emergency transfusion, which is frequently unobtainable in sub-saharan Africa even for children with severe life-threatening anaemia, many of whom die awaiting transfusion (26,27). Standard of care: paediatric critical care approach Cardiac output and organ perfusion in critically-ill children are dependent on the extent of filling of the intravascular compartment. In paediatric and neonatal shock reversal of early stages of shock has been shown to be associated with improved outcome (28). Conversely, delayed intervention or treatment of late decompensated shock is frequently associated with a very poor outcome (29). The optimal fluid and electrolytes for resuscitation require consideration of two major aspects of critical illness physiology. First, what is the extent and nature of any deficits in fluid and electrolytes? Second, does diminished intravascular volume also contribute to clinical presentation thus reducing cardiac output and impairing organ perfusion? While simple electrolyte solutions given either intravenously or orally are appropriate where excess water and electrolyte depletion are involved, principally as a result of dehydration (intracellular losses), in other conditions such as septic shock that involve the loss of intravascular volume (both relative and absolute) the optimal solutions include isotonic crystalloidal or colloidal solutions. These solutions are necessary to restore the filling of the intravascular compartment, restore cardiac output and optimise perfusion to vital organs. Prospective studies Two trials have been conducted to examine volume expansion in severely-malnourished children with shock secondary to diarrhoea or severe sepsis. They were conducted in two phases and aimed to provide detailed data on malnourished children with features of hypovolaemia. In the first phase a single-arm prospective study examined the safety and efficacy of the current WHO shock treatment protocol (2) in up to twenty children with severe malnutrition. In the second phase a phase II randomised controlled trial was conducted to examine the safety and efficacy of different intravenous replacement regimens compared with the standard WHO protocol (control). Phase 1 intervention. The single-arm trial was conducted on the high-dependency unit with continuous haemodynamic monitoring and comprehensive input output fluid balance. The WHO recommended treatment (2) was followed that includes an initial bolus (15 ml/kg) of halfstrength Ringers lactate (Na content 70 mmol/l) given over 1 h, and if the child improves an additional bolus of 15 ml/ kg is given over 1 h. If the child does not improve after 1 h 10 ml whole blood/kg is given, irrespective of Hb. Phase I results. Recruitment was terminated after six of the seven (86%) children enrolled into this study died. The seventh child died later, after transfer from the highdependency unit. Most deaths were a result of uncorrected shock; however, a number of treatment challenges were noted that were corrected for in phase II. In particular, feeding was commenced only after the child had been stabilised and ileus had been excluded and was withheld in those children developing osmotic diarrhoea. Phase II safety and efficacy randomised controlled trial. This trial compared the WHO recommended treatment for shock (for details, see phase 1 intervention) with full-strength Ringers lactate (Na 154 mmol/l) in the group with diarrhoea and in the group with septic shock a threearm trial compared the WHO treatment with 5% (w/v) albumin or full-strength Ringers lactate. In those receiving full-strength Ringers lactate or 5% (w/v) albumin the initial bolus of 15 ml/kg was infused over 1 h, and this treatment was repeated if the child remained in shock. It was recognised that this approach was exceptionally cautious, but an attempt was made not to introduce a potential imbalance in the volumes received compared with the current WHO guideline. Phase II trial summary. In a planned interim analysis mortality across the trial was noted to be high; thirty-three of the sixty-one children died (54%). There was a nonsignificant trend towards a higher mortality in the WHO arm compared with the Ringers lactate arm. In all arms (WHO, Ringers lactate and albumin) the safety of the intervention fluids was demonstrated. In particular, no clinical features of fluid overload pulmonary oedema (defined as bilateral basal crepitations and an O 2 saturation of <90% on air) or evidence of cardiac failure were observed. We concluded that fluid resuscitation with an isotonic solution should be re-evaluated prospectively in dose-escalation studies or by end-point-directed treatment. Myocardial function and response to treatment Optimal cardiac function is important for the maintenance of haemodynamic stability. Myocardial dysfunction and alterations of vascular tone are major complications in severely-ill patients and play a major role in patient morbidity and mortality (30,31). Alterations in normal cardiac and haemodynamic function are exacerbated by perturbations of acid base balance, electrolytes and micronutrients
5 Severe malnutrition: therapeutic challenges 5 and relative adrenal impairment. If treated early enough these factors are amenable to rapid correction by commonly-available therapies such a fluid resuscitation to correct shock and correction of hypoglycaemia and of electrolyte imbalance (hypokalaemia and hypocalcaemia). In severe malnutrition there are limited data on cardiac function in children, with conflicting conclusions (32 36).A study in Jamaica concluded, on the basis of reduced cardiac output, that there was marked impairment of cardiac function (32). A study on Zairian children indicated that many children have signs of an adaptive hypocirculatory state and some show frank peripheral circulatory failure comparable with hypovolaemic shock (33,37). Neither of these studies examined the response to volume expansion or other therapies. Cardiac output studies Two-dimensional echocardiographic examinations using GE Logiq book portable echocardiography (GE Medical Systems UK, Chalfont St Giles, Bucks., UK) have been undertaken as well as Doppler assessment of cardiac output using an ultrasound cardiac monitor (USCOM ultrasonic cardiac output monitor; USCOM Ltd, Sydney, NSW, Australia; Fig. 1), which uses anthropometric data to compute systemic vascular resistance. Initial examinations were conducted in children with clinical features of shock just before or after fluid resuscitation stabilisation of the child. Evidence of cardiac failure is not supported by the findings. Markedly reduced cardiac output concurrent with increased systemic vascular resistance was observed (Fig. 2). This finding is frequent in children with septic shock (38), and was supported by evidence of reduced preload (data not shown). Taken together with the finding of the fluid trial these results point to substantial volume depletion and reduced cardiac output. Lessons learned from feeding the size O There are many parallels in these findings with the experience of nutrition experts managing severely-malnourished (a) (b) Doppler assessment of aortic or pulmonary blood flow Echocardiography Fig. 1. An example of readings from (a) two-dimensional echocardiographic examinations of children with clinical features of shock undertaken just before or after fluid resuscitation stabilisation using GE Logiq book portable echocardiography (GE Medical Systems UK, Chalfont St Giles, Bucks., UK) and (b) Doppler assessment of cardiac output (aortic or pulmonary blood flow) using an ultrasound cardiac monitor (USCOM ultrasonic cardiac output monitor; USCOM Ltd, Sydney, NSW, Australia). populations with complex causes of starvation. In the 2008 meeting of BAPEN a dedicated session on feeding the size 0 has enabled some comparisons to be made (for example, see Cockfield & Philpot (39) ). What is apparent is that there are many lessons to be learned across the specialities, from Africa to UK and vice versa. The clinical experience of managing severe malnutrition in Africa, which is complicated by severe electrolyte perturbations, shock and complex complications of gastroenteritis, have also been highlighted in the management of difficult complex gastroenterological and nutritional problems and the refeeding syndrome (40). The risk of development of the refeeding syndrome was discussed and common factors identified, SVR CO (l/min) Fig. 2. Simultaneous measurement of cardiac output (CO; using an ultrasound cardiac monitor (USCOM ultrasonic cardiac output monitor; USCOM Ltd, Sydney, NSW, Australia)) and systemic vascular resistance (SVR; which is computed by the USCOM ultrasonic cardiac output monitor using anthropometric data) in children with clinical features of shock just before or after fluid resuscitation stabilisation, which shows evidence of underfilling of the intravascular compartment.
6 6 K. Maitland including the severity of the underlying malnutrition, overaggressive nutritional support in the early stages before adequate supplements of phosphate, thiamine, K and Mg and associated conditions that exacerbate micronutrient, electrolyte and mineral depletion (40). Summary Resolving some of the complex and unresolved clinical therapeutic issues of African children with severe malnutrition requires a multidisciplinary approach that may benefit from including international experts in nutrition, gastroenterology, paediatric sepsis and critical care. This approach could be the basis on which to develop a programme of severe malnutrition research to address the fundamental scientific and treatment gaps that result in high in-hospital mortality in children with severe malnutrition in Africa. Valuable lessons may be learned by sharing experiences with specialists managing complex nutritional problems on both sides of the equator. Acknowledgements The data presented would not have been possible without the valued contributions of the following: Alison Talbert, Nahashon Thuo and Charles Chesaro in the prospective studies of diarrhoea in malnutrition; Sophie Yacoob, Hans Joerg Lang and Mohommed Shebbe in relation to myocardial function in severe malnutrition; Samuel Akech, Molline Tibwa and Japhet Karisa in the phase I and II fluid resuscitation trials. The KEMRI-Wellcome Trust Programme received a Wellcome Trust Major Overseas Award to support its core scientific activities (grant no ). The author declares no conflict of interest. References 1. Schofield C & Ashworth A (1996) Why have mortality rates for severe malnutrition remained so high? Bull World Health Organ 74, Ashworth A, Khanum S, Jackson A et al. (2003) Guidelines for the Inpatient Treatment of Severely Malnourished Children. New Delhi, India: WHO Regional Office for South- East Asia. 3. Heikens GT (2007) How can we improve the care of severely malnourished children in Africa? PLoS Med 4, e Heikens GT, Bunn J, Amadi B et al. (2008) Case management of HIV-infected severely malnourished children: challenges in the area of highest prevalence. Lancet 371, Cartmell E, Natalal H, Francois I et al. (2005) Nutritional and clinical status of children admitted to the malnutrition ward, Maputo central hospital: a comparison of data from 2001 and J Trop Pediatr 51, Ashworth A, Chopra M, McCoy D et al. (2004) WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors. Lancet 363, Puoane T, Sanders D, Chopra M et al. (2001) Evaluating the clinical management of severely malnourished children a study of two rural district hospitals. S Afr Med J 91, Nathoo KJ, Bannerman CH & Pirie DJ (1999) Pattern of admissions to the paediatric medical wards (1995 to 1996) at Harare Hospital, Zimbabwe. Cent Afr J Med 45, Deen JL, Funk M, Guevara VC et al. (2003) Implementation of WHO guidelines on management of severe malnutrition in hospitals in Africa. Bull World Health Organ 81, Manary MJ & Brewster DR (2000) Intensive nursing care of kwashiorkor in Malawi. Acta Paediatr 89, Karaolis N, Jackson D, Ashworth A et al. (2007) WHO guidelines for severe malnutrition: are they feasible in rural African hospitals? Arch Dis Child 92, Briend A (2003) Management of severe malnutrition in children in tropical climates. Med Trop (Mars) 63, Ahmed T, Ali M, Ullah MM et al. (1999) Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol. Lancet 353, Collins S & Sadler K (2002) Outpatient care for severely malnourished children in emergency relief programmes: a retrospective cohort study. Lancet 360, Brewster DR (2006) Critical appraisal of the management of severe malnutrition: 1. Epidemiology and treatment guidelines. J Paediatr Child Health 42, Brewster DR (2006) Critical appraisal of the management of severe malnutrition: 3. Complications. J Paediatr Child Health 42, Maitland K, Berkley JA, Shebbe M et al. (2006) Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol? PLoS Med 3, e Collins S & Myatt M (2000) Short-term prognosis in severe adult and adolescent malnutrition during famine: use of a simple prognostic model based on counting clinical signs. JAMA 284, Collins S & Yates R (2003) The need to update the classification of acute malnutrition. Lancet 362, World Health Organization (1999) Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers. Geneva: WHO. 21. Mbori-Ngacha DA, Otieno JA, Njeru EK et al. (1995) Prevalence of persistent diarrhoea in children aged 3 36 months at the Kenyatta National Hospital, Nairobi, Kenya. East Afr Med J 72, Brewster DR, Manary MJ, Menzies IS et al. (1997) Comparison of milk and maize based diets in kwashiorkor. Arch Dis Child 76, Alam NH, Hamadani JD, Dewan N et al. (2003) Efficacy and safety of a modified oral rehydration solution (ReSoMaL) in the treatment of severely malnourished children with watery diarrhea. J Pediatr 143, World Health Organization/UNICEF (2001) Reduced osmolarity oral rehydration salts (ORS) formulation. whqlibdoc.who.int/hq/2001/who_fch_cah_01.22.pdf. 25. Hahn S, Kim S & Garner P (2002) Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. Cochrane Database of Systematic Reviews, issue 1, CD Chichester, West Sussex: John Wiley and Sons Ltd. 26. English M, Ahmed M, Ngando C et al. (2002) Blood transfusion for severe anaemia in children in a Kenyan hospital. Lancet 359, Bojang KA, Van Hensbroek MB, Palmer A et al. (1997) Predictors of mortality in Gambian children with severe malaria anaemia. Ann Trop Paediatr 17, Han YY, Carcillo JA, Dragotta MA et al. (2003) Early reversal of pediatric-neonatal septic shock by community
7 Severe malnutrition: therapeutic challenges 7 physicians is associated with improved outcome. Pediatrics 112, Carcillo JA, Davis AL & Zaritsky A (1991) Role of early fluid resuscitation in pediatric septic shock. JAMA 266, Merx MW & Weber C (2007) Sepsis and the heart. Circulation 116, Goldstein B, Giroir B & Randolph A (2005) International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 6, Alleyne GA (1966) Cardiac function in severely malnourished Jamaican children. Clin Sci 30, Viart P (1977) Blood volume changes during treatment of protein-calorie malnutrition. Am J Clin Nutr 30, Viart P (1977) Hemodynamic findings in servere proteincalorie malnutrition. Am J Clin Nutr 30, Phornphatkul C, Pongprot Y, Suskind R et al. (1994) Cardiac function in malnourished children. Clin Pediatr (Phila) 33, Kothari SS, Patel TM, Shetalwad AN et al. (1992) Left ventricular mass and function in children with severe protein energy malnutrition. Int J Cardiol 35, Viart P (1978) Hemodynamic findings during treatment of protein-calorie malnutrition. Am J Clin Nutr 31, Parker MM, Hazelzet JA & Carcillo JA (2004) Pediatric considerations. Crit Care Med 32, Suppl., S591 S Cockfield A & Philpot U (2009) Managing anorexia from a dietitian s perspective. Proc Nutr Soc 68 (In the Press; doi: /S ). 40. Stanga Z, Brunner A, Leuenberger M et al. (2008) Nutrition in clinical practice the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr 62,
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firefighter Hoodie Sweater Fire Department Sweater Sweatshirt firefighter Gift hoodie
firefighter Hoodie Sweater Fire Department Sweater Sweatshirt firefighter Gift hoodie This PREMIUM COTTON UNISEX Hoodie Sweater is made of Pre-shrunk 75% COTTON and 25% Polyester. For a top-shelf experience, go with this high-quality blended Gildan sweatshirt that is heavy enough to endure the cold as well as the years.Key Features: preshrunk 75% ring-spun cotton/25% polyester 8.5-oz. matching jersey-lined hood 2" rolled forward shoulders contrast dark grey twill neck tape 1x1 fashion rib with spandex pouch pocket#### HOODIE SIZE CHART ####For the size chart please check second image#### MORE COLORS AVAILABLE #### Hooded Sweatshirt COLOR: BLACK, available sizes - S, M, L, XL, 2XL. Hooded Sweatshirt COLOR: NAVY, available sizes - S, M, L, XL, 2XL. SHIPPING: This item will be shipped within 1-3 days after the payment is received. Delivery time for International orders is 2-3 weeks plus our processing time. Delivery to Canada takes 1-2 weeks.For store policies please check the following link: www.etsy.com/shop/MilkyWayTshirts/policy
Weight (lbs.):0.5
Ships To
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Puerto Rico
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Returns not accepted. Custom products cannot be returned.

subset: commoncrawl


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Bronchitis is essentially an inflammation of the mucous membranes of the bronchi. This inflammation will reduce the amount of air flowing in to the lungs, thereby reducing the oxygen supply to the blood stream. There are two types of bronchitis: acute and chronic.
Acute bronchitis is because of illness caused by viruses and bacteria (virus accounts to 90% of bronchitis cases). In case of acute bronchitis the patient will have cough with or without sputum.
Chronic bronchitis, a type of COPD (Chronic obstructive pulmonary disease); it is characterized by the presence of a cough that lasts for three months to at least two years. Chronic bronchitis happens mainly because of recurrent injury to the airways caused by inhaled irritants. Cigarette smoking is the single major cause, followed by exposure to cement, SO2, nitrogen dioxide and other irritants.
There are other minor causes like improper breathing techniques, severe changes in climatic condition and high doze medicines.[box type="info" ]Number of noninstitutionalized adults with diagnosed chronic bronchitis in the United States over last year: 10.1 million[/box]
Home Remedies for Bronchitis
Honey & Pepper:
One teaspoon of honey mixed with a pinch of pepper taken thrice a day is a good symptom reliever for bronchitis.
Garlic is an excellent anti-inflammatory agent and is believed to bring the airway back to normal.
Sesame and Flax Seeds:
A sweet made out of flax seeds, sesame seeds and honey is an excellent medicine for bronchitis. This is an effective treatment for bronchitis, and in addition to that it is nutritious and acts as a wholesome food supplement. [know more about sesame and flax seeds]
Ginger, Long Pepper & Black Pepper:
Dried ginger powder, long pepper and black pepper mixed in equal quantity is considered to be the best medicine for any form of respiratory disease. This is an extremely effective treatment for bronchitis. [learn more about the scientific basis of how Ginger and Long Pepper works]
Turmeric mixed in milk alleviates the symptoms, it also helps in curing acute bronchitis, as it is a proven anti-bacterial and anti-viral agent. [know more about turmeric's medicinal value]
Thoodhuvalai – Solanum Trilobatum
Thoodhuvalai (Scientific name is Solanum Trilobatum) is a night shade plant belonging to the solanum family. It is a powerful medicine for any respiratory disease. It controls cough and eases the air passage in the respiratory system. [know more about Solanum Trilobatum]
Pranayama provides a permanent cure for this disease. There are several kinds of pranayama, however shambhavi mahamudra and agni pran are very effective in curing this disease.


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If you are considering a new commercial, industrial or residential construction project, tenant improvement or expansion, you will be required to go through some type of "Design and Development Approval Process." ...And, If you are not familiar with this procedure, it can be a bit overwhelming!
Even for what appears to be a simple project, Local, State and Federal bureaucracy makes the Design and Approval process complicated. However, by selecting the right design team that will help you understand how the process works, you can greatly increase the chances of success for your project.
Contact us to learn more. We are here to help you through the Design and Development Approval Process for your project.


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This Tiny Winery Fits Inside a Manhattan Apartment
If you thought your home or apartment was crowded, think again.
One resident of the East Village in New York City has fit an entire winery in his 550-square-foot apartment.
Matt Baldassano has been making wine for several years in his small apartment. He has several oak barrels of wine fermenting, a steel barrel filled with even more wine, and an electric crushing machine.
But the most impressive part? He has two tons of grapes (that's 4,000 pounds!) stored in his backyard. Of course, we're also impressed that he managed to find an East Village apartment with a backyard.
→ Read more: This Guy Put an Entire Winery in His 500-Square Foot NYC Apartment from Yahoo! Food
Published: Jul 13, 2015


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Assets provided for private use: HS210 Self Assessment helpsheet
Help with the Employment pages of your Self Assessment tax return.
This guide shows you how to work out the value of an asset provided for your private use because of your employment. HM Revenue and Customs is not producing a version of this helpsheet for 2016 onwards.
Published 4 July 2014
Last updated 6 April 2017 + show all updates
Last updated 6 April 2017 + show all updates
- HM Revenue and Customs (HMRC) is not producing a 2017 version of this helpsheet, no further helpsheet versions to be added from 2016 onwards.
- Rates, allowances and duties have been updated for the tax year 2015 to 2016.
- First published.


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Deena Cortese wearing black furry boots on July 26.
Photo: Getty Images
• Even though it's the middle of July, Deena rocked the same furry boots Snooki previously rocked. Both Jersey ladies boldly defy fashion rules and Mother Nature.
• Kristin Cavallari appeared in a Life & Style wedding dress photo shoot two days before calling off her engagement. We hope she dyes her dress black and wears it to the Chateau Marmont.
• Kristen Stewart, Selena Gomez, and Miley Cyrus went for the see-through shirt trend. We're still wondering if this trend is transparent.
• Katy Perry wore a Smurfette dress and matching nails on the blue carpet of the Smurfs premiere. Is it just us or is she trying to say something here?
• Teen Wolf Tyler Posey posed in all gray at Comic-Con. His mega-wattage smile took the muted look from colds-ville to hots-ville.
• Emma Watson might launch an evening wear fashion line. We can't wait to see what her sewing machine (elegantly) spits out.
• Jared Leto got tangled in his own sweater on the cover of Dedicate magazine. We could get tangled up in that, too.
Like us on Facebook so we can be friends and follow us on Twitter @MTVstyle to talk.


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Spring cold snaps are causing some frost concern around the state, but so far no real threat has materialized. Even the foothills of Calaveras County were not appreciably affected by recent snowfall at 3,000-foot elevations just above many vineyards.
"We didn't have any frost last Wednesday (April 11) even though there was a little snow at elevations right above us," says Matt Hatcher with Hatcher Winery in Calaveras County. One of his vineyards is just south of Angels Camp at an elevation of about 1400 feet. "It didn't get cold enough and we had enough wind to keep us fairly protected," he says. "However, they are still forecasting a few storms that could be cold enough to cause us problems."
On the northern coastal region, the rain provided welcome relief to growers who need to replenish reservoirs. Temperatures stayed well above frost levels for an added bonus.
"Last week's temperatures fell into the 30s," says John Enquist, president of Mendocino Winegrape and Wine Commission. "It wasn't a big deal. We're a lot more worried about getting enough rainfall. We're probably 33 percent short of where we should be at this time of year. If we don't get more soon, it's going to be an issue."
That could be good for winemakers and consumers, but not entirely good for wine grape growers. "Right now, we're looking forward to a season with some pretty intense fruit," Enquist says.


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International version of Japan's Xperia Z1 f inbound?
Ever since Japan's NTT Docomo got the Xperia Z1 f — a 4.3-inch version of the Xperia Z1, with all the juicy specs left intact — we've been hoping for news of a wider international launch. Now there's the first sign that such a device might be headed our way, as the usually reliable @evleaks has published images of a Sony "Xperia Z1S." The shot appears to show a smaller Xperia Z1 with similar button placement and software, but right now that's all we have to go on.
If it's anything like the version due to be sold in Japan, this handset should pack a Snapdragon 800 CPU, 2GB of RAM and a 20.7-megapixel Exmor RS rear camera — in essence, all the internal hardware that matters — along with a smaller 4.3-inch 720p display. Time will tell what form the "Xperia Z1S" eventually takes, but the shortage of high-end Android phones with top-level specs right now means there's definitely an audience for this kind of device.
Source: @evleaks


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From the Sorella Vita bridesmaids collection, the 8472 is a "Maid Your Way" Convertible Chiffon gown with Satin belt. Features two streamers on the front and two on the back of the dress – drape, twist or wrap the streamers to create more than 18 different looks.
With endless possibilities, Maid Your Way is the perfect way to mix up looks to enhance each bridesmaid's unique personality, style and body. It is available in over 30 different colour options.
Please note that colours displayed online, may vary to the colour of our sample in store.
Sample Location: Newport


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independent secondary options for boys in Cambridge?(51 Posts)
Am i understanding this correctly -- are there really only 2 independent school options for boys in Cambridge, The Perse and the Leys? We are moving to Cambridge this summer. My son will be Y9 in the autumn. Is The Leys even a good option for a Day student -- I can't imagine it would be so great to be one of the few who don't stay overnight? And The Perse, well, my son is bright and keeps up good grades, but really likes to have time for fun.
I don't have a big issue with Independent vs State school, being a product of the American state schools myself, but my husband has been bragging to me for 15 years about how amazing English private schools are and how American schools can't even come close, so I think he will be very disappointed....
Our son might be able to pass admission tests for the Perse (he's a smart kid, if a bit lazy at times), but I think we have missed all the deadlines already anyway...
What other independent secondaries do people living near Cambridge look into for the boys?
Not sure what you mean by the 'likes to have time for fun' bit? Do you think he'd have to work super hard and long hours to keep up or that the Perse works them so hard they don't have free time. If the latter take a good look at the Perse website, lots of stuff about wellbeing, rounded individuals etc which might reassure you.
Stephen Perse is going mixed from Sept 2017 but I think it starts with the Yr 7 intake so wouldn't be an option for Yr 9 entry - you might want to double check that though.
I think there are other schools such as Heritage in town that are mixed however that is pretty different from Perse/Leys I believe. Beyond that you have to look further afield (and plenty of people in Cambridge do that). Options to consider would include Kings Ely and perhaps Friends in Saffron Walden (now called something else - Walden School perhaps?).
The entrance tests for The Perse for year 9 this September were last weekend so if you want to have any chance of getting in there you will need to act fast and ask whether he is still able to take the entrance exam.
People have a very weird perception of The Perse and assume it is some sort of hot house. It isn't, honest! There is plenty of time for extra curricular in and out of school.
I currently have 4 year 10s upstairs here!!
As regards the Leys I think many of the offers are on a day boarder basis (ie. they stay for activities, dinner and prep and are collected at 9/9.30ish) so it might be worth checking if your son has out of school activities.
I'm glad to hear that my first impression of reading about Perse was misinformed. I suspect my son would flourish in a work hard/play hard environment. DH went to St Paul's, so he would like The Perse.
At this point, from what I understand, it's too late to be considered along with the current set of applicants.... I think we have to wait until February and see if any places are left.... Or if anything opens up due to attrition.
The Leys is not for us, since it's mostly boarding. And I have no interest in Day Boarding either.
I also have a Y4 son - but Y4 does not appear to be a standard entry point for any of the Preps -- I'm sure he will be way down the waitlist at Perse... But it looks like there are lots of independent Prep schools, so he might have more options. I've got my eye on St. Faith's for him, but again, they say we have to wait til late February to see what's left.
For DD (Y7), I am looking into St. Mary's. I can't quite wrap my mind around the concept of an all-girls school, but the more I think about it, it might be actually be ideal. St Faith's does have Y7-8 but I keep thinking it might be weird for her to start there at Y7.
Finding school places for 3 kids from abroad is enough to make me pull my hair out! I thought it was pretty good to know this far in advance of a relocation, but it looks like we needed to know even a few months earlier...
Actually some people will enter St Faith's at year 7 if eg. They are leaving the state primary after yr 6. Have you thought of The Perse for your daughter too? Are you going to be living in central Cambridge or nearby. If so then King's Ely would probably have space for both year 4 and year 7 as it is still in Junior section of school.
Kings Ely looks interesting option, will keep it in mind, especially if nothing else seems to be working out.
We don't know where we'll live yet. Either in Cambridge not far from the Perse or a larger village south (Great Shelford?). We'd rather live on the S side of the city since we have a lot of family in N London and West of London (and know no one in Cambridge). It will depend on where we can find a house to rent and also upon where we find school places. Work is not far from Cambridge Station.
I think my boys have better personality fit for The Perse, but we'll see about DD as well.
Thanks for all the advice!
I think Sancton Wood also takes boys. But OP I would urge you to consider the state schools too, especially if you yourself have no problem with state education. Lots of them are good, in and around Cambridge. Otherwise if you don't fancy the Leys or the Perse, King's Ely might be the way to go.
Yes but I would assume that Sancton Wood is very possibly full as it has such small class sizes and if the kids are sporty it doesn't really offer school sport as such.
Great Shelford is a very popular choice as the Senior Independents are all this side of Cambridge.
If you fancy meeting up for a coffee when you get here feel free to PM>
The Perse has apparently had record applicants this year so your chances of getting in having missed the exam may not be great. I think you may have missed the Leys exam too as it's around the same time. They do have day students too though, about a third are I think.
Kings Ely is commutable from Cambridge, (though also 2/3 boarders) and you could also consider Culford, who I think to a pick up from some of the Cambridge park and ride sites. Worth looking at state schools too, especially if they're close to where you'll be living.
Kings Ely is not 2/3 boarders only about 10% board
I have children at kings ely and there are loads of children who get the minibus from the science park or the train.
It works really well a great community.
School is fabulous. My children love it and are doing v well.
Hi Ladies. OP here. Sorry I dropped out for a bit - I have been waiting (and waiting...) for my husband's job transfer to officially go through... It is finally signed, sealed and delivered. He starts next month. We join him in July. No house, no schools, but we're coming.
Thanks for all the advice. We are flying over to Cambridge the week after Easter and staying for 8-10 days. I'm planning visits to schools, etc. It's a mess trying to cram all this in, evaluating multiple schools for each of 3 kids, but I want to get it all done so I don't have to fly back until we make the big move.
DD Y7 and DS Y4 -- I've spoken with the local independent preps and St. Mary's and registered the kids at schools with reserve places. We will tour and do assessment when we are in Cambridge.
DS Y9 is still the tricky one.... We won't know for a couple of weeks whether The Perse or The Leys have reserve places, but it doesn't look promising. And DH doesn't like the vibe from The Leys. I personally like what I've learned, sounds like camp to me! But Saturday school- yikes I think that might be a deal breaker.
Anyway, I'm getting more curious about King's Ely. I hadn't really considered it since it is in another town. But from posts on Mumsnet and also from talking to others I've connected with in Cambridge, it sounds like an option I should consider. Please do tell me anything you know about King's Ely.
I'm also getting more curious about the state secondaries. I had considered living outside of the city, but now I'm determined to live in the city. We've done the suburban thing for 15 years. Time for a change. I want to be able to walk places. I'm weary of driving kids everywhere.... I want the kids to have independence.
I'm hoping to visit a couple of state secondaries while we are in town. I realize we don't have an address yet, but this whole process is all messed up for us anyway. At this point, we end up with the dregs of private or state sector. Any recs for decent state secondaries that don't fill up with the first set of applications?
Thanks again for all your advice so far!
Chesterton is a very good school, and has lots of international families like yours that do come and go, so you might be lucky and get a space. Parkside very central and also a good school. St Bede's a bit further out but also very popular if you have any religious credentials. Don't know what your housing budget is but if you can afford de freville or kite areas your DS could easily get to Parkside or Chesterton on a bike and your other children would also be able to get to St Mary's . I don't know anything about Kings Ely I'm afraid . Good luck!
Yr7 Sep allocations (state) cane out this week - is your DD Yr7 now or going into in Sep?
I have the oversubscribed / still have places section of the letter if she is going into Yr7 in Sep that might be useful to you?
I also meant to say that Cambridge is an ideal small city to give your kids independence. Mine have walked/cycled to school unsupervised since Year 5 and it's very common for secondary kids to cycle a couple of miles to get to school. And there's plenty for young people to do and get involved with.
If you look on Cambridgeshire county council website it will tell you which state schools still have places for Y7 entry in September. I'm not sure whether your DC2 is Y7 now, or will be in the autumn. If they're starting schools at other times (as your Y9 child definitely will be) it's a bit random which schools may have places, as it just depends when people leave. So you wouldn't necessarily get the least popular ones.
Living in central Cambridge is great if you can afford it, and worthwhile if you are likely to end up with DC at different schools, as there's quite a few within walking/cycling range. The south side of the city is probably best if you're considering the independent ones, as they're all over that side (and for Kings Ely you'd want to be near the station, which is also south side). As an American you'll probably find the central Cambridge houses rather tiny though!
We have found King's Ely to be great. Lovely school, much more open to diversity and flexible in approach than the Leys. No Saturday school. Easy to get to by train, many kids travel from Cambridge or further. Teaching is very good, and the ability level of students is improving as more and more people look beyond the Cambridge schools. Also flexi boarding option if they need to stay late for rehearsals, debates etc.
Wow, you guys are great!! this is all so helpful.
First, yes, DD is going into Yr7 in the autumn.
It looks like we can afford housing in city. The main issue seems to be that all the sizable rentals appear to be geared toward students and sharers, rather than a single family rental.... We know we won't get the size of an American home, but we still need some space with 3 kids...... We could probably get a bigger place in Great Shelford, but at this point, I'm holding out for in city. I know we have to, but I'm really not looking forward to renting. Ugh. I haven't rented in 20 years.... I can't bear not being able to paint the walls, etc....
Really nice to hear good things about Chesterton. It was actually one I was looking at, especially since Parkside will be full, St. Bedes probably too, and while the kids are technically Catholic, we don't go to church enough to get an endorsement anyway. I will ring Monday and find out if there are any Chesterton places left. Then there is Netherhall. Good south city location but looks huge! I'll follow up.
I've been reading the Ofsteds of the in city state secondaries. Yikes. Why are they almost all "Requires Improvement?" Except the ones that are always oversubscribed. Geez. What's up with that? How do you feel about signing up for a school that is officially marked as struggling? Very disconcerting.
It's all so different from how they do state school placement where I live in the US. Basically, each residential address is assigned to a school. Period. It doesn't matter when you move there, you still get a spot in that school. Even mid-year arrivals. And exceptions are very rare. If you want a certain school, then you get a house in that area.
Anyway, you guys make me feel like maybe I can actually pull this off. I love that you confirm my thoughts that Cambridge city would be a great place for the kids to get around on their own. It's ironic that American' culture values independence over almost everything else. However, outside of some of the very big cities (NYC, Boston, etc), we are much more set up for driving everywhere than public transport, and this results in parents becoming taxi drivers for their kids activities.... In the end, the kids don't get the very independence that is so highly valued in American culture. (until they get kicked out of the house after graduation at 18, which is actually not unusual).
I've contacted King's Ely as well. I'm really hoping to hit all the schools of interest in the 10 days we are visiting.
Thanks again.
Don't worry too much about Ofsted. Not the be all and end all. Chesterton is a really good school with lots of sport, music, drama etc. Facilities a little sad and tired but enthusiastic staff, a great Head and a very international and interesting student body.
How many bedrooms do you need as a minimum, OP?
Only asking because this would be a great rental. It doesn't look particularly promising from the exterior but is Chesterton catchment, 5 mins to the river, near cafes and amenities, and a very easy cycle to city centre. It's the only 4 bed I have found so far that isn't a student house.
But between now and July, more houses may come up...
I checked the school availability list, which may still change. At this point, in city, only Netherhall has Yr 9 places. Chesterton, Coleridge, Parkside, St Bedes are all full. Sawston has 3 Yr9 places.
Also Orchardy- thanks for the house link. We do want 4-5 bedrooms. Minimum 4 for sure.
I do check RightMove and the like sometimes, but since I know availability will change so much by the time we arrive, I try to resist (but mostly give in).... I can get so obsessed looking at houses online! Also, because we do get 60 days temp housing once we move over (while waiting for our stuff to catch up!), it seems we should be able to find something in that timeframe. Shouldn't we? Honestly I have no idea...
I also want to see which independents we get offers. For example, if DS ends up at Kings Ely, proximity to station becomes critical... I realize we can't get state places without an address so I guess we will be at the mercy of attrition. These things are beyond my control, but it is what is. Such a bummer to leave a school where all 3 of my kids are thriving to the great unknown, where all the schools are full and we have to hope things work out. But I do have a good feeling about the whole thing, honestly.
I'm planning to talk to letting agents when we come over in April. Are some letting offices better than others?
A lot can change between now and July/Sept, both for housing and for school places. Cambridge has a very transient population so you could be lucky. I don't know about letting agents as new names seem to pop up all the time, but I'd trust Redmaynes. Good luck - keep us posted.
DS went to Netherhall. It's been through a bit of an unsettled time in the last few years but now has a new head, so I would hope is on the up. It's not bad though. DS was very happy there. It's not particularly big (180 a year ish) I'd have thought Sawston must be bigger. The Perse is similar in size.
As a last resort, be aware that there are rules on the UK that the local authority does have to find you a place somewhere. If necessary they can make a school take a pupil even when it's technically full, so you will definitely get them in somewhere.
Also, when looking for a house, your don't need to go very far out the centre to avoid the student rentals. Students don't tend to live in Chesterton, or anywhere over Hills Road railway bridge to the south of the city.
I just wanted to say that I would not recommend St Faith's or The Leys unless what you are looking for is an English public school experience. Both the Perse schools are more of an independent grammar school set up.
St Faith's is a funny place. It looks and feels comforting when one visits but it's quite regimented and the kind of child they like was - increasingly over the time we were there - nothing like mine. We were there for 5 years and my son came away and had to go up ten levels in maths to be where the state primary he joined thought he ought to be for Yr5.
He got dreadful Effort and Attainment results and a lack of credit where due. In his state primary it's totally different and he's flying academically and just won a place at the Perse.
For some, St Faith's does work but they don't adapt to your child. It's more of a one size must fit all approach.
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WATCH | The National Park Service turned 100 this year, and more people are visiting America's national parks than ever before. But that's actually causing problems at Utah's Zion National Park.
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The organization holds club meetings, similar to a church youth group—"I would describe it as a party with a purpose"—which attracts teenagers who normally would not venture into a church. "Our goal through Young Life is to introduce high school teenagers to Christ," says Alyssa.
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China plans to launch its first cargo spacecraft in April, state media reported today – taking a step towards its goal of establishing a permanently manned space station by 2022.
President Xi Jinping has prioritised advancing China's space programme, saying it was needed to enhance national security and defence. Plans for the maiden voyage of the cargo spacecraft were reported on the front page of the People's Daily, the official Communist Party newspaper.
The Tianzhou-1 cargo resupply spacecraft will be carried into space by a Long March-7 Y2 rocket launched from Wenchang Satellite Launch Centre in south China's island province of Hainan, the daily reported, citing the China Manned Space Agency.
The Tianzhou-1 is designed to dock with the Tiangong 2 space laboratory, or "Heavenly Palace 2", which China used to carry out its longest ever manned space mission last October, sending two astronauts into space for a month aboard the laboratory.
The spacecraft can carry six tonnes of goods, two tonnes of fuel and can fly unmanned for three months, the newspaper said.
For all the advances China has made in its space programme for military, commercial and scientific purposes, it is still lagging the US and Russia.
China's Jade Rabbit moon rover landed on the Moon in late 2013 to great national fanfare, but soon suffered severe technical difficulties.
The US Defence Department has highlighted China's increasing space capabilities, saying it was pursuing activities aimed at preventing other nations using space-based assets in a crisis.
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