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Your Child

Study: Bedtime Routine Offers Kids Many Benefits

1:45

If your child doesn’t have a nightly bedtime routine, he or she is missing out on a tremendous amount of health and behavioral benefits according to a new study. And you’re not alone.

A multinational study consisting of over 10,000 mothers from 14 counties reported that less than 50 percent of their infants, toddlers and preschoolers had a regular bedtime routine every night.

Researchers determined that the participant’s children who did have a regular bedtime routine benefitted on many levels. The study found that children with a consistent bedtime routine had better sleep outcomes, including earlier bedtimes, shorter amount of time in bed before falling asleep, reduced night waking, and increased sleep duration. Children with a bedtime routine every night slept for an average of more than an hour longer per night than children who never had a bedtime routine. Institution of a regular bedtime routine also was associated with decreased sleep problems and daytime behavior problems, as perceived by mothers.


“Creating a bedtime routine for a child is a simple step that every family can do,” said principal investigator and lead author Jodi Mindell, PhD, professor of psychology at Saint Joseph’s University and associate director of the Sleep Center at Children’s Hospital of Philadelphia. “It can pay off to not only make bedtime easier, but also that a child is likely to sleep better throughout the entire night.”

According to the American Academy of Sleep Medicine, positive bedtime routines involve the institution of a set sequence of pleasurable and calming activities preceding a child’s bedtime. The goal is to establish a behavioral chain leading up to sleep onset. Activities may include giving your child a soothing bath, brushing teeth and reading a bedtime story.

“It’s important that parents create a consistent sleep schedule, relaxing bedtime routine and soothing sleep environment to help their child achieve healthy sleep,” said American Academy of Sleep Medicine President Dr. Timothy Morgenthaler.


Researchers found that consistency was an important factor in helping children sleep well

“For each additional night that a family is able to institute a bedtime routine, and the younger that the routine is started, the better their child is likely to sleep,” said Mindell. “It’s like other healthy practices:  Doing something just one day a week is good, doing it for three days a week is better, and doing it every day is best.”

Mothers participated in the study by completing a validated, online questionnaire that included specific questions about their child’s daytime and nighttime sleep patterns, bedtime routines and behavior. The questionnaire was translated into each language and back-translated to check for accuracy.

“The other surprising finding is that we found that this effect was universal,” said Mindell.  “It doesn’t matter if you are a parent of a young child in the United States, India, or China, having a bedtime routine makes a difference.”

Sleep deprivation is becoming an all too common problem with today’s children and adults. The earlier a good sleep routine can be established and practiced, the better for a child in the long run.

Study results are published in the May issue of the journal Sleep.

Source: http://www.healthcanal.com/disorders-conditions/sleep/63298-study-shows-that-children-sleep-better-when-they-have-a-nightly-bedtime-routine.html

Your Child

Bullying: Kids Helping Kids to Stop

1:45

Being bullied in school can be at the least annoying and at the worse, enough to make someone try to take their own life.

While adults have searched for ways to get the message across that bullying is not acceptable, certain kids who have a high amount of social influence over their peers may be the best resource for reducing the hateful interaction, according to a new study.

Schools with the largest numbers of these "social influencers" had the largest declines in student conflict, the findings showed.

The study included students from 56 New Jersey middle schools who had strong social influence within their peer groups. These kids weren't always the most popular kids in a particular grade, but had influence in their peer group.

The investigators selected the teens using a tool called social network mapping that allowed them to identify the kids who had the most connections, both online and off.

The researchers came up with their own plan and asked the kids to spread messages about the dangers of bullying and more positive ways of handling conflict. These anti-bullying messages were promoted through Instagram, print posters and colorful wristbands.

"We designed our own curriculum because current programs address problems as defined by adults, and they aren't necessarily fitted to each individual school environment," lead author Elizabeth Levy Paluck, an associate professor of psychology and public affairs at Princeton University, said in a university news release.

"We think the best way to change social norms is to have these student influencers speak in their own voices. Encouraging their own messages to bubble up from the bottom using a grassroots approach can be very powerful," she added.

Kids were more likely to choose not to bully or to find other ways of handing stress or anger when their peers made it known that they did not approve.

"When adults choose student leaders, they typically pick the 'good' kids. But the leaders we find through social network mapping are influential among students and are not all the ones who would be selected by adults. Some of the students we find are right smack in the center of student conflicts. But the point is, these are the students whose behavior gets noticed more," she explained.

Source: Robert Preidt, http://consumer.healthday.com/kids-health-information-23/adolescents-and-teen-health-news-719/influential-students-effective-at-bully-prevention-706695.html

Your Child

What to Do If Your Child Is Choking

2.30 to read

It’s more common than you probably think. On average over 12,000 children a year, under the age of 14, are treated in hospital emergency rooms for food-related choking. That’s about 34 kids a day according to a new study.

The most common choking hazards appear to be hard candy, followed by other types of candy, then meat and bones. The study noted that most of the young patients were treated and released, but around 10 per cent were hospitalized.

"These numbers are high," said Dr. Gary Smith, who worked on the study at Nationwide Children's Hospital in Columbus, Ohio.

What's more, he added, "This is an underestimate. This doesn't include children who were treated in urgent care, by a primary care physician or who had a serious choking incident and were able to expel the food and never sought care."

The estimated 12,435 children ages 14 and younger that were treated for choking on food each year also doesn't include the average 57 pediatric food-choking deaths reported by the U.S. Centers for Disease Control and Prevention annually, the researchers noted.

Smith and his colleagues analyzed injury surveillance data covering 2001 through 2009.

They found that babies one year old and younger accounted for about 38 percent of all childhood ER visits for choking on food. Many of those infants choked on formula or breast milk.

Children who choked on hotdogs, nuts and seeds were the most likely to be hospitalized.

"We know that because hot dogs are the shape and size of a child's airway that they can completely block a child's airway," Smith told Reuters Health, noting that seeds and nuts are also difficult to swallow when children put a lot in their mouths at once.

Supervision is the most important choking prevention. Parents or guardians should make sure that a small child’s food is cut up into manageable bites that can be easily chewed and swallowed. An example might be grapes and raisins. A whole raisin is probably okay to be given to a toddler, but a grape should be sliced.

What should you do if your child is choking?

For children ages 1 to 12:

1. Assess the situation quickly.

If a child is suddenly unable to cry, cough, or speak, something is probably blocking her airway, and you'll need to help her get it out. She may make odd noises or no sound at all while opening her mouth. Her skin may turn bright red or blue.

If she's coughing or gagging, it means her airway is only partially blocked. If that's the case, encourage her to cough. Coughing is the most effective way to dislodge a blockage. If the child isn't able to cough up the object, ask someone to call 911 or the local emergency number as you begin back blows and chest thrusts. If you're alone with the child, give two minutes of care, then call 911.

On the other hand, if you suspect that the child's airway is closed because her throat has swollen shut, call 911 immediately. She may be having an allergic reaction to the food.

Call 911 immediately is your child is turning blue, unconscious or appears to be in severe distress.

2. Try to dislodge the object with back blows and abdominal thrusts.

If a child is conscious but can't cough, talk, or breathe, or is beginning to turn blue, stand or kneel slightly behind him. Provide support by placing one arm diagonally across his chest and lean him forward.
Firmly strike the child between the shoulder blades with the heel of your other hand. Each back blow should be a separate and distinct attempt to dislodge the obstruction.

Give five of these back blows.

Then do abdominal thrusts

Stand or kneel behind the child and wrap your arms around his waist.

Locate his belly button with one or two fingers. Make a fist with the other hand and place the thumb side against the middle of the child's abdomen, just above the navel and well below the lower tip of his breastbone.
Grab your fist with your other hand and give five quick, upward thrusts into the abdomen. Each abdominal thrust should be a separate and distinct attempt to dislodge the obstruction.

Repeat back blows and abdominal thrusts Continue alternating five back blows and five abdominal thrusts until the object is forced out or the child starts to cough forcefully. If he's coughing, encourage him to cough up the object.

If the child becomes unconscious If a child who is choking on something becomes unconscious, you'll need to do what's called modified CPR. Here's how to do modified CPR on a child:

Place the child on his back on a firm, flat surface. Kneel beside his upper chest. Place the heel of one hand on his sternum (breastbone), at the center of his chest. Place your other hand directly on top of the first hand. Try to keep your fingers off the chest by interlacing them or holding them upward.

Perform 30 compressions by pushing the child's sternum down about 2 inches. Allow the chest to return to its normal position before starting the next compression.

Open the child's mouth and look for an object. If you see something, remove it with your fingers. Next, give him two rescue breaths. If the breaths don't go in (you don't see his chest rise), repeat the cycle of giving 30 compressions, checking for the object, and trying to give two rescue breaths until the object is removed, the child starts to breathe on his own, or help arrives.

A good rule of thumb for parents and guardians is to take a CPR class. Many hospitals and clinics also offer classes on what to do if your child is choking.

Sources: Genevra Pittman, http://www.reuters.com/article/2013/07/29/us-choking-food-idUSBRE96S04K20130729

http://www.babycenter.com/0_first-aid-for-choking-and-cpr-an-illustrated-guide-for-child_11241.bc

 

Your Child

Recall: Children’s Cough Syrup

1:30

Parents are being urged to check their medicine cabinets as two batches of generic children's cough syrup are removed from pharmacy shelves across the country. They have been recalled due to overdose risk.

The voluntary recall was initiated after it was discovered the dosage cups included in the box had incorrect markings, leading to fears that children may be given too much medication, according to a statement from the manufacturer.

The products in question are:

·      Children's guaifenesin grape liquid (100mg/5 mL)

·      Children's guaifenesin DM cherry liquid (100mg guaifenesin and 5mg dextromethorphan HBr/ 5 ml) sold in 4 oz. bottles

Each includes a small plastic cup.                  

The over-the-counter cough syrups are sold generically nationwide, under different brand names:

GUAIFENESIN GRAPE LIQ 4 OZ

·      H.E.B

·      CVS

GUAIFENESIN DM CHRY LIQ 4 OZ

·      Sunmark

•       Rite-Aid

•       Topcare

•       Kroger

•       GoodSense

•       Dollar General

•       Care One

•       CVS

The U.S. Food and Drug Administration said it is aware of the voluntary recall and urged consumers who bought the batches listed above "to discard the dosing device and product."

While there have been no reported overdoses related to the medication, the Perrigo Company said side effects of an overdose can include "hyperexcitability, rapid eye movements, changes in muscle reflexes, ataxia, dystonia, hallucinations, stupor and coma," adding that other effects have included "nausea, vomiting, tachycardia, irregular heartbeat, seizures, respiratory depression and death."

Source: Amy La Porte, http://www.cnn.com/2016/01/12/health/childrens-cough-syrup-recalled/

Your Child

Asthmatic Kids Breathe Easier With Smoke-Free Air

For children with asthma, reducing exposure to environmental tobacco smoke greatly decreases their chance of an asthma flare-up, hospital admission or ER visit.

A new study shows that for children with asthma, reducing exposure to environmental tobacco smoke greatly decreases their chance of an asthma flare-up, hospital admission or emergency room visit. "We found this to be true when the child's exposure (to second-hand smoke) decreased, even if the decrease did not mean completely eliminating their exposure," said Dr. Lynn B. Gerald of the University of Arizona in Tucson. "Any reduction in environmental tobacco smoke exposure seems to greatly benefit these children."

Dr. Gerald's team looked at the association between changes in environmental tobacco smoke exposure and childhood asthma-related illness in 290 asthmatic children enrolled in a clinical trial of supervised asthma therapy. The average age of the children in the study was 11 years and 80 percent had moderate persistent asthma. At the beginning of the study, 28 percent of caregivers reported that the child was exposed to second-hand smoke in the home and 19 percent reported exposure to smoke outside the home only. At a follow-up interview, 74 percent of caregivers reported no change in the child's exposure to second-hand smoke, 17 percent reported less exposure, and 9 percent reported increased exposure. According to the report, which is published in the medical journal Chest, children who had any decrease in exposure to second-hand smoke over the course of one year had fewer episodes of poor asthma control, made fewer respiratory-related trips to the emergency room and were less apt to be hospitalized than children who had the same or increased exposure to second-hand smoke. "We were not surprised by the findings but we were surprised by the magnitude of the benefit that decreasing smoke exposure appeared to have," said Dr. Gerald. She said doctors can use this information as another "teaching point" for caregivers and parents of children with asthma. Dr. Gerald and her colleagues also concluded given that the majority of second-hand smoke exposure in the home is due to parents smoking, "the most effective environmental tobacco smoke reduction strategy may be to provide smoking cessation interventions to parents and possibly other household members."

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Your Child

Healthier Choices for Students in School Lunch Lines

1:30

School lunches have changed over the years and in many school cafeterias, food options are healthier than ever before, according to a new study.

Elementary school cafeterias are offering more vegetables, fresh fruit, salad bars, whole grains and more healthy pizzas, while the availability of high-fat milks, fried potatoes and regular pizza has decreased, researchers report.

"School food service programs have worked hard to improve the nutritional quality of school lunches, and largely have been very successful," said lead researcher Lindsey Turner, director of the Initiative for Healthy Schools at Boise State University, in Idaho.

Although in some schools food choices are improving, that’s not the case everywhere. Turner noted that more work needs to be done to make sure every student has the same healthy choices in the lunch line.

In the study of more than 4,600 elementary schools that are part of the U.S. National School Lunch Program, researchers found that school lunches improved significantly between 2006-2007 and 2013-2014.

Despite improvements in food choices, disparities were still found. For example, schools in the West were more likely to offer salad bars than schools in the Northeast, Midwest or South, the researchers found.

Schools with a majority of black or Hispanic children were less likely to offer fresh fruit than schools with a preponderance of white students.

Also, schools in poor areas were less likely to offer salads regularly.

Over the course of the study, Midwestern schools slightly reduced offering pre-made salads in favor of salad bars, but Southern schools were more likely to offer pre-made salads and less likely to have salad bars, the researchers found.

On the other side of offering healthier foods is choosing to eat those foods. Just because there are better food options available, doesn’t mean that kids will eat them. One expert noted that it takes time and effort for kids to change their eating habits. It not only has to look good, it has to taste good.

"It is not only important to improve the quality of school lunches but to make these foods attractive, tasty, easily seen and accessible," said Samantha Heller, a senior clinical nutritionist at New York University Medical Center, in New York City.

Studies have found that putting fresh fruit in a nice bowl, in a conveniently located, well-lit area in the school cafeteria increased sales of fruit by 102 percent, she noted.

"A brightly lit, hot-and-cold salad bar filled with colorful fresh fruits, vegetables, beans and nuts, mushroom and spinach pizza, and veggie tacos center-stage in the lunchroom would be very attractive to students and staff alike," Heller said.

This approach works well at home, too, she added.

"Kids are more likely to grab healthy foods like cut-up melon, carrots, peppers, edamame and hummus when they are upfront and easy to grab in the fridge," Heller said.

The study was published in the journal Preventing Chronic Disease.

Story source: Steven Reinberg, http://consumer.healthday.com/vitamins-and-nutrition-information-27/food-and-nutrition-news-316/america-s-school-lunches-getting-healthier-study-709097.html

Your Child

It’s Official; CDC Says Flu is Epidemic

2:00

The flu has reached epidemic levels in the United States, with 15 children dead so far this season, the federal Centers for Disease Control and Prevention (CDC) reported at the end of December 2014.

Every year, the U.S. reaches a point where the number of flu cases enters the epidemic stage.  There’s no way to tell right now if this year’s flu season will end up being more or less severe than previous ones. Those statistics won’t be available till later in the year.

No state will be spared this season with more flu cases and deaths’ increasing in the next few weeks says Dr. Michael Jhung, a medical officer in CDC's influenza division. "We are in the middle of flu season," Jhung said. "It's a safe bet that we are going to see flu activity continue to increase for a few more weeks. We are going to see every state in the country affected by flu."

The number of children’s deaths from flu changes every year. The latest victim may be a 17 year-old-girl in Minnesota. She was diagnosed with the flu and sent home to recover. Shanna Zwanziger had the flu for about a week before she died says her family. Her mother said Shanna was given the choice of whether to get the vaccine or not, and she chose not to.

The South, Midwest and Western states have been especially hard hit this flu season. At least six children have died in Tennessee and four in Minnesota, according to published reports.

The predominant flu strain this season is the H3N2 virus, the CDC says. This virus is not well matched to this year's flu vaccine, but what part this mismatch is playing in flu deaths isn't known, Jhung said.

The CDC acknowledges that that this year’s flu vaccine is not a good match for the most dominant strain of the virus. That’s because there’s not just one type of flu and the virus can mutate. This year’s vaccine was created before one of the viruses mutated. However, experts say that getting this year’s vaccine can still help protect you and can help make symptoms less severe if you get the flu.

The CDC recommends that everyone 6 months and older get a flu shot. It's not too late to get vaccinated, Jhung said. More than one type of flu is circulating, and the vaccine protects against at least three strains of circulating virus, he added.

"If you encounter one of those viruses where there is a very good match, then you will be well-protected," he said. "Even if there isn't a great match, the vaccine still provides protection against the virus that's circulating."

Many people get the flu and recover at home. They spend anywhere from a few days to a couple of weeks feeling very bad and then start to feel better. But others face life-threatening complications – such as pneumonia- according to the CDC.

Jhung says parents should always take the flu seriously, and get medical help if their child is very sick.

Warning signs might include a cough that disrupts sleep, a fever that doesn't come down with treatment, or increased shortness of breath, according to the U.S. Food and Drug Administration.

There are treatments for the flu such as Tamiflu and Relenza. "Those work best when they are given very quickly. So if you do have signs and symptoms of flu, reach out to a health care provider and get evaluated," Jhung said.

The flu season moves into its later stage in January and February, with different flu types taking the lead. It’s not too late to get your family the flu shot. They are still available at physician’s offices as well as at many pharmacies and health care centers.

Sources: Steven Reinberg, http://consumer.healthday.com/infectious-disease-information-21/flu-news-314/flu-now-epidemic-in-u-s-with-15-child-deaths-reported-695066.html

Liz Neporent, http://abcnews.go.com/Health/years-subpar-flu-shot-save-life/story?id=27898830

Your Child

Young Baseball Pitchers Playing With Pain

2:00

It’s that glorious time of year when pitchers pitch; batters swing and outfielders reach out to catch a fast and furious white leather-bound ball. Yep, it’s baseball season!

While the pros start their 162 game regular season, school teams and Little Leagues are suiting up and hitting the fields as well.

Although typically in good physical shape, professional players are not immune to injuries – just ask the Texas Rangers.

Kids on the other hand, play long and sometimes double games at tournaments on the weekends. Many of these kids are weekend warriors that love the game, but aren’t always in the best physical condition.

According to a pair of recent studies, young baseball pitchers are playing with arm and shoulder pain because they feel pressured by their parents or coaches. Playing through the pain may lead to injuries that won’t heal.

"Kids are playing harder and longer in more leagues than ever before," said Dr. Paul Saluan, director of pediatric and adolescent sports medicine at the Cleveland Clinic. "Kids also are not getting enough rest in between episodes of pitching, which may lead to insufficient time to heal smaller stress injuries. Over time, these smaller injuries add up."

Kids explained why they kept playing even though they were in pain.  "Players who experience pain often felt their parents and coaches were frustrated with them," said Dr. Christopher Ahmad, professor of orthopedic surgery at Columbia University Medical Center in New York City.

"Throwing with pain is a signal that injury is occurring," added Ahmad, who is the New York Yankees' head team physician.

In Ahmad's study, he and his colleagues surveyed 203 healthy players, aged 8 to 18. Just under one-quarter of them had experienced a prior overuse injury, they found.

Almost half of the players -- 46 percent -- said they had been encouraged to continue playing with arm pain, and 30 percent said their arm pain sometimes made playing less fun.

Those most likely to report being encouraged to play despite pain had a previous overuse injury. They were also more likely to report feeling arm pain while throwing and to experience arm fatigue during games or practice.

The second study looked at whether parents were monitoring their child’s pitch count during a game. Sixty parents of baseball pitchers were surveyed and just over half of the parents were not aware of safe pitching guidelines and did not actively monitor their child's pitch count.

The most important aspects of safe pitching guidelines are a maximum number of recommended throws based on a child's age and the number of days of rest needed between throwing stints, said Saluan.

"The focus has been on creating a better athlete who can throw harder, faster and more accurately than ever before," Saluan said. "Injury prevention has taken a back seat."

One in five parents did not know how many pitches their child threw in a typical game, but 64 percent recalled that their child had experienced pain in the upper extremities because of pitching, the survey found. For one-third of the pitchers, the pain required a medical evaluation.

"Kids who continue to pitch through pain end up with significant injuries that may have lifelong consequences," Saluan said. "Younger pitchers who are still growing are much more vulnerable than adults to sustain an injury to the growth plates around the shoulder and elbow.”

Injuries to the growth plates usually heal with rest, Ahmad said. But he noted that more young pitchers are also damaging their ulnar collateral ligament, an important ligament in the elbow.

"Unfortunately, these injuries do not always heal and often require surgery," he said.

Most of the injuries are caused when kids are playing too many games, specializing in one aspect of the game, using poor pitching mechanics and throwing too hard.

In the pitching study, half the young pitchers threw in at least two leagues at a time, one-quarter pitched more than nine months of the year, and just over half participated in extra showcase situations.

"We have fallen into the trap of 'too much too soon,'" said Saluan. "This has resulted in a rise in injury rates in kids whose bodies are not prepared to handle the stresses that are encountered."

If you’re unsure of how to monitor your child’s pitching, the Major League Baseball website has a “Pitch Smart” guidelines page for young and adolescent pitchers listed at the end of this article.

The studies were presented at the American Academy of Orthopaedic Surgeons' annual meeting in Las Vegas. Data and conclusions presented at meetings are usually considered preliminary until published in a peer-reviewed medical journal.

Sources: Tara Haelle, http://consumer.healthday.com/fitness-information-14/baseball-or-softball-health-news-240/young-pitchers-often-pressured-to-play-despite-pain-study-says-697197.html

http://m.mlb.com/pitchsmart/pitching-guidelines

Your Child

Worrisome Increase in Kidney Stones in Teens & Children

1:45

Typically, kidney stones occur in men over the age of 25, but new research shows that the annual incidence of kidney stones among children and teens has risen by 16 percent from 1997 to 2012.

Researchers analyzed data from South Carolina from 1997 to 2012 and were surprised to see that the largest increase was with teens (4.7 percent a year), females (3.7 percent a year) and blacks (nearly 3 percent a year).

During the study period, the risk of kidney stones doubled among children, and there was a 45 percent increase in the lifetime risk for women.

Teen girls had the highest rate of increase in kidney stones, and they were more common among females aged 10 to 24 than among males in the same age group. After age 25, kidney stones were more common in men, the study authors said.

"The emergence of kidney stones in children is particularly worrisome, because there is limited evidence on how to best treat children for this condition," said study leader Dr. Gregory Tasian, a pediatric urologist and epidemiologist at The Children's Hospital of Philadelphia.

"The fact that stones were once rare and are now increasingly common could contribute to the inappropriate use of diagnostic tests such as CT scans for children with kidney stones, since health care providers historically have not been accustomed to evaluating and treating children with kidney stones," he explained in a hospital news release.

"These trends of increased frequency of kidney stones among adolescents, particularly females, are also concerning when you consider that kidney stones are associated with a higher risk of chronic kidney disease, cardiovascular and bone disease, particularly among young women," Tasian added.

What causes kidney stones? According to the Mayo clinic, kidney stones do not have a single cause, although several factors can increase one’s risk.

Kidney stones form when your urine contains more crystal-forming substances — such as calcium, oxalate and uric acid — than the fluid in your urine can dilute. At the same time, your urine may lack substances that prevent crystals from sticking together, creating an ideal environment for kidney stones to form.

Some of the risk factors include a family or personal history of kidney stones, dehydration, diets high in protein, sodium and sugar, obesity and other several other medical conditions.

Symptoms can include:

•       Severe pain in the side and back, below the ribs

•       Pain that spreads to the lower abdomen and groin

•       Pain that comes in waves and fluctuates in intensity

•       Pain on urination

•       Pink, red or brown urine

•       Cloudy or foul-smelling urine

•       Nausea and vomiting

•       Persistent need to urinate

•       Urinating more often than usual

•       Fever and chills if an infection is present

•       Urinating small amounts of urine

If your child or teen exhibits severe back or side pain, pain and nausea and vomiting, pain with fever and chills, blood in the urine or has difficulty passing urine, he or she should be seen immediately by a physician.

There may be a number of reasons for the rise in kidney stone rates, including not drinking enough water and poor eating habits, such as increased salt and decreased calcium intake, the researcher said.

The findings were published online in the Clinical Journal of the American Society of Nephrology.

Source: Robert Preidt, http://teens.webmd.com/news/20160115/rise-in-kidney-stones-in-teens-a-cause-for-concern-study

 

 

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DR SUE'S DAILY DOSE

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