Partha’s Fundamentals of Pediatrics Swati Y Bhave, A Parthasarathy, MKC Nair, PSN Menon
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Pediatric CareChapter 1

• Importance of Pediatrics and Pediatric Care in Developing Countries
YC Mathur
• Primary Health Care
A Parthasarathy
• Maternal and Child Health
A Parthasarathy
2
 
Importance of Pediatrics and Pediatric Care in Developing Countries
YC Mathur
 
INTRODUCTION
Pediatrics is defined as the art (derived from the beliefs, judgements and infusions we cannot explain) and science (derived from the knowledge, logic and prior experience we can explain) of treating childhood illnesses. As such preventive pediatrics is the sheet anchor of pediatric care in developing countries like India.
From a global perspective, the most vulnerable segment of our society are mothers and children. This is true both in “developing” and “developed” countries. Many of the health problems and health needs faced by mothers and children in “developing” countries today are similar to those faced by mothers and children in previous decades in “developed” countries. Infant mortality is one of the most valuable indicators of the status of development of a society or a country. As an indicator, it is closely related to the overall level of well-being in a country or region. It reflects not only food, clean water, medical and health care, but also the actual availability of such basic resources to all segments of a population. High infant mortality rate is associated with certain social problems, e.g. environmental contamination, lack of education of mothers, poor health care, the disadvantaged position of women, in the society, etc. In searching out the explanation of infant deaths, two levels of analysis are needed: One to identify the immediate causes of death, and another to examine the social, economic, or environmental conditions that make infants vulnerable to these immediate causes.
 
MATERNAL AND CHILDCARE
The immediate cause of a baby's death may be lack of food, a disease, a severe birth defect, extreme low birth weight, or an injury. But underneath most infant deaths is likely to be a mosaic of low family income, lack of sanitation, crowding, high fertility, or exposure to toxic substances. Many of these direct and indirect causes interact, so that it may be difficult to pinpoint one single factor alone which causes the death of an infant. Because infant mortality is so closely tied to broad social and economic conditions, the most decisive gains to be made in reduction of infant mortality involve improvements in sanitation, water supply, nutrition, access to medical and health care, fertility control and education.
 
Factors Influencing Infant Mortality
  1. Education of the mother.
  2. Provision of clean water.
  3. Interval between births.
  4. Birth order.
  5. The type of feeding of the infant.
  6. Birth weight of the baby.
  7. Maternal health care.
 
INFANT AND UNDER 5 MORTALITY
Approximately 19 million children in the world die each year from the combined effects of poor nutrition, diarrhea, malaria, pneumonia, measles, whooping cough, and tetanus. Virtually these deaths could be prevented with relatively simple measures already available to us. Six diseases (measles, whooping cough, tetanus, tuberculosis, polio, and diphtheria) kill 5 million children a year in the developing world, and account for approximately one-third of all childrens' deaths; we have effective immunizing agents against all these six diseases. Each day, more than 60,000 young children in the world die of a combination of malnutrition and infection. It is estimated that the adoption of specific measures like oral rehydration therapy (ORT), immunization, the growth chart and breastfeeding could reduce these deaths of children. It is estimated that one out of every 20 children born in the developing world dies before reaching the age of 5 years.
Study of levels and trends in infant and early childhood (0–4 years) mortality reported to the UN/WHO shows a wide range. The highest reported U5MRs (under five mortality rates) are in general from Africa, south of the Sahara, followed by Asia, 3Latin America, Europe and Oceania in that order. In all countries studied, mortality has declined over time. On the average, there were 43 fewer deaths of five years under the age per 1,000 births than 15 to 19 years earlier, a 28 percent reduction in mortality. The number of deaths prevented per 1,000 births is about evenly divided between infants (20 deaths) and other ages (10 toddlers and 13 pre-schooler deaths averted). At least 10 to 15 percent of babies are born with low birth weight; they account for 30 to 40 percent of all infant deaths in the developing world. One of the specific factors known to have an effect on birth weight is maternal nutrition.
 
INFANT AND CHILD MORTALITY
Infant and child mortality rates reflect a country's level of socioeconomic development and quality of life and are used for monitoring and evaluating population and health programs and policies.
Neonatal mortality (NM)
: The probability of dying in the first month of life.
Postneonatal mortality (PNM)
: The probability of dying after the first month of life but before the first birthday.
Infant mortality (IM)
: The probability of dying before the first birthday.
Child mortality (CM)
: The probability of dying between the first and fifth birthdays.
Under-five mortality (U5M)
: The probability of dying before the fifth birthday.
The overall infant mortality rate declines sharply with increasing education of mothers, as expected, ranging from a high of 87 deaths per 1,000 live births for illiterate mothers to a low of 33 deaths per 1,000 live births for mothers who have at least completed high school. Other mortality indicators vary similarly with mother's education. As one would expect, mother's education has a stronger positive effect on postneonatal and child mortality than on neonatal mortality (which is strongly affected by biological factors).
Children of women belonging to scheduled castes and scheduled tribes have higher rates of infant and child mortality than children of women belonging to other backward classes or upper middle class women. Children of upper middle class women have by far the lowest rates of infant and child mortality. As expected, all indicators of infant and child mortality decline substantially with increases in the household standard of living. For example, for children in households with a high standard of living the infant mortality rate (IMR) is 43 deaths per 1,000 live births and the under five mortality rate is 52 deaths per 1,000 live births; the corresponding rates for children in households with a low standard of living are more than twice as high at 89 and 130, respectively as compared to households with a high standard of living. The postneonatal mortality rate (PNMR) is almost three times as high in households with a low standard of living, the child mortality (CMR) rate is almost five times as high, and the neonatal mortality rate is almost twice as high. Similar differentials in infant and child mortality by mothers' education, religion, caste/tribe and living standard are observed in both urban and rural areas.
 
LOW BIRTH WEIGHT FACTOR
Another important determinant of the survival changes of children is the baby's weight at the time of birth. Many studies have found that low birth weight babies (LBW) (under 2,500 grams) have a substantially increased risk of mortality. Because most babies in India are not weighed at the time of birth, in addition to birth weight, mothers were asked whether babies born during the three years preceding the survey were “large, average, small, or very small” at birth.
 
MALNUTRITION
Rates of malnutrition are a good indicator of overall child health. A crude estimate of global trends in malnutrition in children under 5 years of age indicates no change in relative terms, but a growing malnutrition problem in absolute numbers. Malnutrition in infants and young child commonly consists of protein-energy malnutrition, marasmus, vitamin A deficiency including severe xerophthalmia in South East Asia and severe iodine deficiency in countries like Nepal and Bhutan.4
Malnutrition caused by poor child feeding practices usually claims over 10 times as many children as actual famine. Coupled with dehydration due to diarrhea, malnutrition is the leading killer in the world, killing 5–8 million children a year, at least 10 percent of all deaths. It is caused by a combination of poor sanitation, infectious diseases such as measles, failure to breastfeed, poor weaning practices, especially the failure to safely and adequately supplement breast milk after 5 or 6 months of age. The most effective defense against diarrhea, malnutrition, and infections includes nutrition education, breastfeeding, safe and careful food supplementation, safe and careful weaning, oral rehydration therapy, immunization and safe basic sanitation (water supply and sewage disposal).
When a baby is breastfed, its exposure to contaminated water, food and utensils is usually limited. One of the major protections to babies in developing countries is the breastfeeding that most of them have during the first several months of life or longer. Furthermore, mother's milk contains antibodies that increase the baby's resistance to infection. In the first 5 to 6 months of life, breast milk contains the nutrients essential for early growth.
 
DIARRHEA AND ORT
It is estimated that 500 million children have attacks of diarrhea 3 to 4 times a year. Each year, four million young children in developing countries die due to diarrhea. The majority of these diarrhea deaths are due to dehydration, which could be prevented by oral rehydration therapy (ORT). If applied correctly, it can prevent an estimated 90 percent of the current 4 million diarrhea deaths in children under 5 years in the developing countries. But less than 15 percent of the world's families are using this low cost treatment for preventing and treating diarrheal dehydration which is the biggest single killer of children in the world today.
Diarrhea is the second most important killer of children under age five worldwide, following acute respiratory infection. Deaths from acute diarrhea are most often caused by dehydration due to loss of water and electrolytes. Nearly all dehydration-related deaths can be prevented by prompt administration of rehydration solutions. Because deaths from diarrhea are a significant proportion of all child deaths, the Government of India has launched the Oral Rehydration Therapy Program as one of its priority activities for child survival. One major goal of this program is to increase awareness among mothers and communities about the causes and treatment of diarrhea. Oral rehydration salt (ORS) packets are made widely available and mothers are taught how to use them.
 
MONITORING OF GROWTH
This consists of the large-scale use of simple cardboard child growth charts kept by the mothers in their own homes as a stimulus and a guide to the proper feeding of the infant and preschool child. Regular monthly weighing and the entering of the results by the mother herself can make early malnutrition visible to the one person who cares most and can do the most about improving the child's diet.
 
FAMILY WELFARE
Each year in the poorer countries of the world, between 10 and 20 percent of children never live to see their first birthday—a total of 10 million infant deaths in the developing world. Most of these deaths are preventable. High levels of neonatal, infant and childhood mortality, as well as maternal mortality, are associated with or result from the poor nutritional status of women, complications of pregnancy and childbirth, low birth weight and conditions of the perinatal period, such as malnutrition and infection. Regulated fertility can prevent both maternal and infant mortality.
It is estimated that 45 percent of the women of the world are delivered at home by an untrained birth attendant. Thus, we may say that the one person most likely to be used to provide primary care to women of the childbearing age around the world is the untrained traditional birth attendant. It is for this reason that the trained birth attendant (TBA) is now looked upon by the World Health Organization and by many Ministries of Health around the world as one of the major resources to provide primary care in the network of organized MCH services in developing countries. In India, an estimated 600,000 ayahs attend 80 percent of all births.
 
IMMUNIZATION
The WHO Expanded Program on Immunization (EPI) began in 1974. The aim was to immunize all children 5by 1990. Also termed “Universal Child Immunization” (UCI-1990) WHO/UNICEF has set the target to eradicate poliomyelitis by the year 2000. The toll of childrens' deaths in developing countries from the five communicable diseases of childhood is enormous. It is estimated that five million such deaths occur each year. Every six seconds, a child dies and another is disabled from a disease for which there is an effective immunizing agent. The common communicable diseases of childhood are also the cause of malnutrition in children, especially measles and whooping cough. All of the immunizable communicable diseases are driving forces in the cycle of malnutrition and infection, which retard the growth of millions of children who survive the infections themselves. In one study in Africa, measles was found to be the precipitating cause in half of the cases of hospitalization for malnutrition. Immunization against the six communicable diseases is also a preventive measure against malnutrition.
The vaccination of children against six serious but preventable diseases (tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and measles) has been a corner stone of the child health care system in India. As part of the National Health Policy, the National Immunization Program is being implemented on a priority basis. The Expanded Programme on Immunization (EPI) was initiated by the Government of India in 1978 with the objective of reducing morbidity, mortality and disabilities from these six diseases by making free vaccination services easily available to all eligible children. Immunization against poliomyelitis was introduced in 1979–80, and tetanus toxoid for school children was added in 1980–81. Immunizaton against tuberculosis (BCG) was brought under the EPI in 1981–82. The latest addition to the program was vaccination against measles in 1985–86.
The Universal Immunization Program (UIP) was introduced in 1985–86 with the following objectives; to cover at least 85 percent of all infants against the six vaccine preventable diseases by 1990, to achieve self-sufficiency in vaccine production and the manufacture of cold-chain equipment. This scheme has been introduced in every district of the country and the target now is to achieve 100 percent immunization coverage. Pulse Polio Immunization Campaigns began in December 1995 as part of a major national effort to eliminate polio. By 2005 remarkable decline has occurred in all the six vaccine preventable diseases throughout India.
 
INFECTIOUS DISEASES
 
Acute Respiratory Infection
Acute respiratory infection, primarily pneumonia is a major cause of illness among infants and children and the leading cause of childhood mortality throughout the world. Early diagnosis and treatment with antibiotics can prevent a large proportion of ARI/Pneumonia deaths. A simple intervention strategy by Health Worker at field level. viz.
  1. Looking for fast breathing, and
  2. Chest indrawing
    Will detect most cases of pneumonia and with immediate referral to the appropriate center, the infant/child will receive adequate antibiotics and other supportive measures and thus many precious lives could be saved.
 
Asthma
The prevalence of asthma is considerably higher in rural areas (2,649 per 100,000 population) than in urban areas (1,966 per 100,000 population), and is slightly higher among males (2,561 per 100,000) than among females (2,369 per 100,000). Age differences are marked, with the prevalence of asthma increasing from 950 per 100,000 at age 0–14 to 10,375 per 100,000 at age 60 and over.
 
Tuberculosis
The overall prevalence of tuberculosis in India is 544 per 100,000 population. The prevalence of tuberculosis is much higher in rural areas (600 per 100,000) than in urban areas (390 per 100,000).
 
Malaria
Rural residents are almost twice as likely to suffer from malaria (4,254 per 100,000) and urban residents (2,156 per 100,000).
 
INFANT FEEDING PRACTICES
The Baby Friendly Hospitals Initiative, launched by the United Nations Children's Fund (UNICEF), recommends initiation of breastfeeding immediately 6after childbirth. The World Health Organization (WHO and UNICEF) recommend that infants should be given only breast milk for the first six months of their life. Under the Reproductive and Child Health Program, the Government of India recommends that infants should be exclusively breastfed from birth to age 6 months (Ministry of Health and Family Welfare, New Delhi). Most babies do not require any other food or liquids during this period. By age seven months, adequate and appropriate complementary foods should be added to the infant's diet in order to provide sufficient nutrients for optimal growth. It is recommended that breastfeeding should continue, along with complementary foods, through the second year of life or beyond. It is further recommended that a feeding bottle with a nipple should not be used at any age, for reasons related mainly to sanitation and prevention of infections.
 
Primary Health Care
A Parthasarathy
 
INTRODUCTION
Amongst the major causes of high infant mortality and the large number of handicapped children in many tropical countries are childhood diseases which respond to the availability of immunization and/or effective prevention or to simple treatments. A policy of primary health care adapted to the particular country can be the most effective and the least costly solution. It must provide screening for the treatment of the most common diseases, and their systematic prevention by community action: improvement of hygiene and nutrition, vaccination, preventive treatments and education of both children and adults. An essential ingredient for success is collaboration between all levels of health professionals and the population.
 
ESSENTIAL COMPONENTS OF PRIMARY HEALTH CARE POLICY
  1. Improvement of basic hygiene: Personal hygiene, care of sores, disposal of dirty water and garbage.
  2. Adequate supply of drinking water: Provision of drinking water, at first communal and then into individual homes, necessary for improving hygiene and food and for medical care, abolishing the need for water storage which is often dangerous, as well as for the hard work of carrying water.
  3. Participation of the community:
    • People: on health committees and as community health personnel and in other ways;
    • Material: loans of premises and equipment, organization of public transport;
    • Financial: providing free medical or paramedical services do not necessarily matter much. On the other hand, when the same funds are well managed, they can be invested in the development of improved health care and sanitation for the community (e.g. buildings, installation of facilities, drugs and vaccines).
  4. Health and hygiene education: It should be at the personal and community levels.
  5. Organization of facilities and the application of appropriate methods of treatment:
    • Distribution of health care units, setting up of referral centers, and co-ordination of their activities.
    • Providing “essential medicines”.
  6. Maternal and child care, including family welfare.
  7. Improvement of nutritional status:
    • Evaluation of nutrition
    • Nutrition education
    • Prevention of malnutrition, including the early treatment of diarrhea (oral rehydration and nutritional management).
  8. Expanded program on immunization.
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Example: A campaign of immunization protects against the diseases covered by the campaign, but:
  • In the absence of health education: If the population immunized is not told which illness it is protected against, the credit attributed to vaccination is lost or is reduced when another disease occurs.
  • Without the participation of the population: If the population plays no personal, financial or material part in the program, it will not feel involved, and there may be no self-financing for the provision of vaccines not available free of cost.
  • In the absence of basic hygiene: If the basic hygiene of the population is not improved, other diseases may occur and the effect of the immunization may be reduced.
  • Without appropriate treatment protocols: If the technique of immunization is unsuitable, if the instruments are contaminated or if the cold chain is interrupted at any stage, the vaccine may be ineffective or may even cause local or general complications, and the program will be discredited
  • If the nutritional state is inadequate: The immunization will not be effective.
  • Without appropriate methods of treatment: If there is no program of oral rehydration to accompany the other programs and the immunization program, children will still die of diarrhea.
  • In the absence of maternal and child health programs: If the child population is badly targeted and if one forgets vulnerable or specially sensitive age groups, there will be incorrect vaccine coverage of the region and child mortality will remain high.
 
SUMMARY
Given the size of the task, it is necessary to:
  1. Co-ordinate action: Primary health care must be integrated with all other actions so as to improve general community development, particularly health;
  2. Integrate the multidisciplinary teams: All the teams involved (maternal health, child health, mental health, public health, technology, finance and administration) must strive together towards the same goal;
  3. Improve general health care: If the level of health in a whole population is to be changed, one must consider the health of all rather than that of individuals;
  4. The results of the work must be evaluated, with research which will allow future improvements and the introduction of new methods.
 
Maternal and Child Health
A Parthasarathy
 
INTRODUCTION
Maternal and child health (MCH) is an essential component of primary health care (PHC) policy. Effective protection of the health of the child begins by promoting the health of the mother. Child health promotion, which is central to MCH, has the following aims:
  1. To ensure optimum growth.
  2. To protect against constant risks which threaten:
    • During pregnancy and childbirth, particularly in early life
    • From infections
    • Malnutrition
    • Poisoning
    • Accidents and other hazards
  3. To diagnose and effectively manage the curable diseases.
  4. To help overcome handicaps.
Protection of the child mainly involves:
  • Health surveillance
  • Monitoring
  • Prevention
  • Informing and educating the family
  • Diagnosis and treatment.8
 
Management of Pregnancy
  1. Aims:
    • Supervision and monitoring of normal pregnancy
    • Screening for at-risk pregnancies, and transfer to REFERRAL centers.
  2. Every pregnant woman must be examined at least once every trimester. The information obtained at each visit should be recorded to make a clear and precise picture of the progress of the preg nancy, recording the last menstrual period and the expected date of delivery; in addition, record;
    • Anti-tetanus immunization status
    • Number of previous pregnancies and labors
    • Number of living, deceased and stillborn children, and of abortions
  3. The clinical notes on clinical history will contain an assessment of maternal risk factors:
    • Previous serious illness (e.g. tuberculosis, diabetes, heart disease, hypertension)
    • Young age (<16 years)
    • Grand multiparity (>6)
    • Past obstetric history (Cesarean section, forceps, vacuum extraction, hemorrhage)
    • Previous pregnancy(-ies) resulting in stillbirth
    • Short stature (<150 cm)
    • Malnutrition and severe anemia
      If one or more risk factor(s) is (are) present, one must consider early TRANSFER of the patient before the onset of labor.
  4. At each visit, the duration of the pregnancy should be checked; clinical examination should include:
    • Weight, blood pressure
    • Presence and site of edema
    • Test for proteinuria
    • Fundal height
    • Auscultation of fetal heart sounds
    • Presentation of the fetus
    • Examination of the uterine cervix
    • Vaginal blood loss (history and/or clinical examination)
    • Temperature
  5. The antenatal examination should also include a search for urinary tract infection, trauma, abortion (and curettage) and vaginal blood loss; medical treatments, both prescribed and taken, must be recorded.
    The following laboratory examinations should be done:
    • Examination for parasites
    • Hematology
    • Urinary sediment and proteinuria
    • Blood group
    • Wasserman reaction
    • Screening for AIDS.
  6. The ninth month is the time to complete the list of risk factors by clinical examination:
    • Unengaged head
    • Breech or transverse presentation
    • Severe anemia
    • Toxemia of pregnancy (marked edema, proteinuria, hypertension (>140 mm Hg).
      Again, where there is (are) one or more risk factor(s), it is time to transfer the patient to the REFERRAL center.
  7. Management of pregnancy also includes:
    • The prevention of anemia by prescribing anti-parasite drugs, iron and folic acid
    • Prophylaxis against malaria
    • Anti-tetanus vaccination
  8. The promotion of good health in pregnancy by information and education should concentrate on:
    • Health and nutrition education
    • Making the future mother aware of family planning
    • Hygiene of the mother and new baby
    • Breastfeeding.
 
Confinement (Delivery)
  1. Normal confinements can be carried out at home, provided midwives are available. At-risk or complicated pregnancies must be sent for their confinement to a REFERRAL center (with labor room and infant resuscitation equipment).
  2. Evaluation of the newborn at birth:
    • Just after birth, ligature and section of the umbilical cord with sterile material. The newborn has to be dried with a clean towel; it is not necessary to bathe the newborn
    • The upper airways have to be cleaned and, if possible, a gentle nasal and pharyngeal aspiration will be performed with an adapted and sterile nasal tube
    • Evaluation of risk factors and resuscitation of the newborn.
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Postnatal Visit
The postnatal visit can be combined with the first examination of the neonate; this will include a clinical examination of mother and child, and advice about breastfeeding. Family planning advice will also be given; it will be prescribed or administered at that time, according to circumstances.
 
Monitoring the Infant
The first consultation must occur within the first month. Weighing and measuring are essential to regular surveillance, the findings are recorded and graphed; explanations should be given to the mother about her infant's growth and development. In this way, she will learn the significance of these measurements and be motivated to bring her baby again.
The mother should also be questioned about:
  • How the child is being fed (breastfeeding, supplementation, introduction of solids)
  • A medical history (risk factors, e.g. sickle cell trait, neonatal disorders)
  • The infant's immunization status
  • Family history and significant recent events in the family.
The clinical examination should particularly seek signs of malnutrition (weight/height ratio) and of dehydration.
Management of the child should include:
  • Immunization (see vaccinations)
  • Prophylaxis against malaria, gut parasites, anemia, and other locally prevalent diseases
  • The treatment of diseases (including fever, diarrhea, skin sores, simple burns, malnutrition and parasitoses)
  • Screening for sensory handicaps.
 
Health Promotion
Health promotion through education is essentially concerned with:
  • Advice on hygiene and nutrition, including the production of fresh fruit, vegetables, etc. to vary the diet
  • Immunization
  • Prevention of accidents.
 
Health, Hygiene and Nutrition Education at the Community Level
Besides nutritional and sanitary education in the course of individual consultation, PHC has the important duty of health, hygiene and nutrition education at the community level.
  1. This must be adapted to the way of life of the population (local habits, e.g. food, living conditions, hygiene, different roles of different family members).
  2. It must respond to the needs expressed by the population or made apparent by the incidence and prevalence of certain diseases.
  3. It must not be limited to theoretical instruction, but include practical matters such as:
    • The organization of the nutrition rehabilitation center
    • The construction, extension and maintenance of primary health care centers
    • Taking measures against insects and other parasite vectors
    • The upkeep of a vegetable garden
    • Small scale animal breeding
    • Garbage disposal
    • Construction and maintenance of wells and latrines
    • Community demonstrations (cooking, recipes, first aid for the injured, oral rehydration, transport for the sick and wounded, storage and protection of foodstuffs).
  4. It must involve all family members (including fathers) and the whole community (including elders).
 
Organization
The organization of PHC activities is the responsibility of the personnel of the health center, in close collaboration with the regional health team and guided by the responsible doctor who decides what actions are to be taken in the light of previous experience.
A system of case record, however modest, which is entirely in the hands of the villagers and health center personnel, is of great importance. These records (personal health records) should contain:
  1. Medical information (growth, weight curves, vaccinations and medical care) to give a clear and precise picture of the health of the child quickly 10and to improve coordination between antenatal management, the maternity hospital, the care of the infant and his/her later management;
  2. Information about the family and its socio-economic circumstances.
This information must be of high quality and readily available to reliably assess the incidence and prevalence of disease and to permit the identification of priority tasks and the evaluation of interventions and treatments.
BIBLIOGRAPHY
  1. Mathur YC, et al. Social Pediatrics in Hyderabad. The Bombay Hospital Journal 1973;15(1):55–57.
  1. Philippe Goyens, Paul Jacques Lamotte. Maternal and Child Health, Tropical Pediatric Hand Book, Nestle Nutrition Sciences,  Switzerland, 1996;2:8–9.
  1. Philippe Goyens, Paul Jacques Lamotte. Primary Health Care. Tropical Pediatrics Hand Book, Nestle Nutrition Sciences,  Switzerland 1996;1:6–7.