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Tips of the Week for December, 2014

Fever and Pain Medicine: How Much To Give Your Child
12-29-2014

Parents need to be aware of a major change in infant’s and children’s liquid acetaminophen products (such as Tylenol) available on store shelves. Since Summer 2011, some manufacturers have changed the amount of acetaminophen in these medicines to one standard amount. Infant drops, which contain 3 times more medicine than the children’s liquid, will be phased out and no longer available. However during this transition, you may find both concentrations on store shelves and in your home.

Parents need to be aware that the dosing amounts are different depending on the concentration they are using.

Why the change?

The change to one concentration for all children is being done to help reduce dosing errors that can lead to accidental overdoses. Too many times parents have mistaken the strength of the infant drops, which are stronger than the liquids, and accidently given their children too much medicine.

What to do

Always call your pediatrician before giving acetaminophen to a child under 2 years of age, and call right away if your child is under four months of age and has a fever. Be sure when calling that you know which concentration you have, either 80mg/0.8mL (these are the drops which are being discontinued) or 160mg/5mL (children’s liquid). You can find this information on the front of the medicine bottle.  Have the bottle with you when you call.

For children over the age of 2 years, check the label to see how much medicine to give. If you know your child's weight, use that. If you do not know your child’s weight, go by age for the dose amount.

Important reminders

  • Keep all medicines out of the reach of children
  • Use only the dosing device that comes with the product
  • Never give adult medicines to children
  • Always read and follow the instructions on the label
  • Talk to your pediatrician if you have any questions
  • If you think your child has taken too much of this or any medicine, call poison control at 800.222.1222

Information provided by HealthyChildren.org.  For additional information and links, please go to http://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/Fever-and-Pain-Medicines-How-Much-to-Give.aspx

 Last Updated 5/11/2013

Source:  American Academy of Pediatrics (Copyright © 2011)

The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances

 


Children, the Flu, and the Flu Vaccine
12-22-2014

Influenza is dangerous for children

Influenza (“the flu”) is more dangerous than the common cold for children. Each year, many children get sick with seasonal influenza; some of those illnesses result in death.

  • Children commonly need medical care because of influenza, especially before they turn 5 years old.
  • Severe influenza complications are most common in children younger than 2 years old.
  • Children with chronic health problems like asthma, diabetes and disorders of the brain or nervous system are at especially high risk of developing serious flu complications.
  • Each year an average of 20,000 children under the age of 5 are hospitalized because of influenza complications.
  • Flu seasons vary in severity, however some children die from flu each year. During the 2013-2014 influenza season, more than 100 flu-related pediatric deaths were reported. More information about pediatric deaths since the 2004-2005 flu season is available in the interactive pediatric death web application.

The single best way to protect your children from the flu is to get them vaccinated each year.

The seasonal flu vaccine protects against the influenza viruses that research indicates will be most common during the upcoming season. Traditional flu vaccines (called trivalent vaccines) are made to protect against three flu viruses; an influenza A (H1N1) virus, an influenza A (H3N2) virus, and an influenza B virus. In addition, there are flu vaccines made to protect against four flu viruses (called “quadrivalent” vaccines). These vaccines protect against the same three viruses as the trivalent vaccine and an additional B virus.

What kinds of flu vaccines are available for children?

  • The trivalent flu vaccine protects against three flu viruses; two influenza A viruses and an influenza B virus. The following trivalent flu vaccines will be available:
    • standard dose trivalent shots that are manufactured using virus grown in eggs. These are approved for people ages 6 months and older. There are different brands of this type of vaccine, and each is approved for different ages.
  • The quadrivalent flu vaccine protects against four flu viruses; two influenza A viruses and two influenza B viruses. The following quadrivalent flu vaccines will be available:
    • a standard dose quadrivalent shot. One brand is approved for people 6 months and older while others are approved for those 3 years and older.
    • a standard dose quadrivalent nasal spray, approved for healthy* non-pregnant people 2 through 49 years of age (recommended preferentially for healthy children 2 to 8 years old when immediately available and there are no contraindications or precautions).

Starting in 2014-2015, CDC recommends use of the nasal spray vaccine (LAIV) for healthy* children 2 through 8 years of age, when it is immediately available and if the child has no contraindications or precautions to that vaccine. Recent studies suggest that the nasal spray flu vaccine may work better than the flu shot in younger children. However, if the nasal spray vaccine is not immediately available and the flu shot is, children 2 years through 8 years old should get the flu shot. Don’t delay vaccination to find the nasal spray flu vaccine. For more information about the new CDC recommendation, see Nasal Spray Flu Vaccine in Children 2 through 8 Years Old or the 2014-2015 MMWR Influenza Vaccine Recommendations.

(*“Healthy” in this instance refers to children 2 years through 8 years old who do not have an underlying medical condition that predisposes them to influenza complications.)

A complete list of influenza vaccines that are available for the 2014-15 season can be found on CDC’s influenza website.

Your child’s health care provider will know which vaccines are right for your child.

  • CDC recommends that everyone 6 months of age and older get a seasonal flu vaccine.
    Keep in mind that vaccination is especially important for certain people who are high risk or who are in close contact with high risk persons. This includes children at high risk for developing complications from influenza illness, and adults who are close contacts of those children.

For the complete list of those at high risk, visit People at High Risk of Developing Flu–Related Complications.

There are special vaccination instructions for children aged 6 months through 8 years of age

Some children 6 months through 8 years of age require two doses of influenza vaccine. Children in this age group who are getting vaccinated for the first time, as well as some who have been vaccinated previously, will need two doses. Your child’s health care provider can tell you whether two doses are recommended for your child.

The 2009 H1N1 virus that caused the 2009 H1N1 influenza pandemic continues to circulate. A 2009 H1N1-like virus wasn’t added to the seasonal vaccine until the 2010-2011 flu season. This means that children who did not get the 2009 H1N1 vaccine in 2009-2010, or a seasonal flu vaccine in 2010-2011 or later, will not be fully protected from the 2009 H1N1 virus until they receive two doses of the 2014-2015 flu vaccine.

The first dose should be given as soon as vaccine becomes available.

The second dose should be given at least 28 days after the first dose. The first dose “primes” the immune system; the second dose provides immune protection. Children who only get one dose but need two doses can have reduced or no protection from a single dose of flu vaccine.

If your child needs the two doses, begin the process early. This will ensure that your child is protected before influenza starts circulating in your community.

Be sure to get your child a second dose if he or she needs one. It usually takes about two weeks after the second dose for protection to begin.

Recommendations on the control and prevention of influenza are published annually, in late summer or early fall. Existing recommendations are available at Seasonal Influenza Vaccination Resources for Health Professionals. Updated recommendations for the 2014-2015 season, including the current recommendation regarding the preferential use of nasal spray vaccine in healthy children 2 through 8 years old, is available on the CDC website.

Some children are at especially high risk

Children at greatest risk of serious flu-related complications include the following:

  1. Children younger than 6 months old
    These children are too young to be vaccinated. The best way to protect them is to make sure people around them are vaccinated
  2. Children aged 6 months up to their 5th birthday
    It is estimated that each year in the United States, there are more than 20,000 children1 younger than 5 years old who are hospitalized due to flu. Even children in this age group who are otherwise healthy are at risk simply because of their age. In addition, children 2 years of age up to their 5th birthday are more likely than healthy older children to be taken to a doctor, an urgent care center, or the emergency room because of flu. To protect their health, all children 6 months and older should be vaccinated against the flu each year. Vaccinating young children, their families, and other caregivers can also help protect them from getting sick.

1Thompson W, Shay D, J, Weintraub E, et al. Influenza-Associated Hospitalization in the United States. JAMA 2004; 292 (11):1333-1340.

  1. American Indian and Alaskan Native children
    These children are more likely to have severe flu illness that results in hospitalization or death.2,3

2CDC. Deaths Related to 2009 Pandemic Influenza A (H1N1) Among American Indian/Alaskan Natives --- 12 States, 2009. MMWR. 2009;58(48);1341-1344.
3CDC. Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR. 2010; 59(No.RR-8).

  1. Children aged 6 months through 18 years with chronic health problems, including:
    • Asthma
    • Neurological and neurodevelopmental conditions [including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy (seizure disorders), stroke, intellectual disability (mental retardation), moderate to severe developmental delay, muscular dystrophy, or spinal cord injury].
    • Chronic lung disease (such as chronic obstructive pulmonary disease [COPD] and cystic fibrosis)
    • Heart disease (such as congenital heart disease, congestive heart failure and coronary artery disease)
    • Blood disorders (such as sickle cell disease)
    • Endocrine disorders (such as diabetes mellitus)
    • Kidney disorders
    • Liver disorders
    • Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders)
    • Weakened immune system due to disease or medication (such as people with HIV or AIDS, or cancer, or those on chronic steroids), and
    • Children who are receiving long-term aspirin therapy

Children should be vaccinated every flu season

Children should be vaccinated every flu season for the best protection against flu. For children who will need two doses of flu vaccine, the first dose should be given as early in the season as possible. For other children, it is good practice to get them vaccinated soon after flu vaccine becomes available, ideally by October. However, getting vaccinated even later can be protective, as long as flu viruses are circulating. While seasonal influenza outbreaks can happen as early as October, most of the time influenza activity peaks in January or later. Since it takes about two weeks after vaccination for antibodies to develop in the body that protect against influenza virus infection, it is best that people get vaccinated so they are protected before influenza begins spreading in their community.

*"Healthy" indicates persons who do not have an underlying medical condition that predisposes them to influenza complications.

Additional Information:

Provided by the Centers for Disease Control and Prevention.  For additional information and links, please go to http://www.cdc.gov/flu/protect/children.htm

 

 


What’s the Latest with the Flu? A Message for Caregivers & Teachers
12-15-2014

2014-2015 Influenza Season:

With flu activity for the 2014-2015 season increasing, be sure that your Head Start or early education and child care program is prepared to respond once flu hits your community. Remember that 80% of all influenza illness generally occurs in January, February, and March each year.

Get your Flu Vaccine!

Even though the flu season has already begun, it is not too late to get your flu vaccine, and encourage others to do the same. The American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention (CDC) recommend that all people aged 6 months and older, especially those with chronic medical conditions, receive the flu vaccine. This includes all child care providers and staff. After receiving the flu vaccine, people begin to develop antibodies and should be protected from the flu about 2 to 4 weeks later. Everyone needs a flu vaccine each year because immunity wears off over time. This is true even when the virus strains in the vaccine do not change from the previous year, as is the case this flu season.

As you may know, there are 3 or 4 flu virus strains included in each year's flu vaccine. This year, one of the flu strains that is circulating does not match what is in the vaccine. This may lead to a decrease in vaccine effectiveness against this particular virus (H3N2). The AAP continues to recommend that all children 6 months and older (and their caregivers), who are eligible for influenza vaccination, be immunized against influenza as soon as possible. It also highlights the importance of influenza antiviral treatment as a valuable second line of defense for children with influenza.

Prevent the Spread of Germs:

Once flu starts circulating, it can be challenging to keep germs from spreading. It is also hard to know whether children or caregivers actually have the flu. Some people can be infected with the flu virus but have no symptoms. During this time, those persons may still spread the virus to others.

Policies in your child care center can limit the spread of the influenza virus and should focus on hand washing; cleaning, sanitizing, and disinfecting surfaces and toys; and excluding children and caregivers who are sick. Any child with respiratory symptoms (cough, runny nose, or sore throat) and fever should be excluded from their child care program. The child can return after the fever has resolved (without the use of fever-reducing medicine), the child is able to participate in normal activities, and staff can care for the child without compromising their ability to care for the other children in the group.

It is also a good idea to assess the knowledge of the staff in your program in regards to the flu and offer influenza prevention education for staff. Encourage caregivers to:

  • Review the AAP Influenza Prevention and Control Information for Caregivers and Teachers Fact Sheet.
  • View the Archived AAP Webinar: View the 90-minute AAP webinar: "Improving Head Start/Child Care and Community Readiness and Response to Seasonal Influenza." This webinar will help staff to increase their knowledge of important influenza prevention and control strategies for this year's influenza season.
  • Complete Online Training: Take the free 1-hour AAP/CDC online course "Influenza Prevention & Control: Strategies for Early Education & Child Care Providers." This course educates staff who work in Head Start and other early education and child care programs about influenza policies and strategies that help keep children healthy. The course is approved for 1.0 contact hour.
  • Display Materials: Display educational materials in Head Start or other early education and child care facilities to encourage proper hand hygiene and cough/sneeze etiquette.
  • Learn More: Review the AAP Managing Infectious Disease Outbreaks chapter. This chapter outlines important strategies to assist in preparing for and identifying a potential outbreak. Seasonal influenza and enterovirus-D68 can lead to similar symptoms. To ensure the health of the children in your care, the AAP recommends that caregivers and teachers be vigilant about managing infectious diseases (e.g. emphasize the need for immunizations, and implement infection control and exclusion practices). The AAP has also developed information for parents and child care programs and schools on EV-D68.

Additional Resources:

Published 12/12/2014 12:00 AM by HealthyChildren.org.  For additional information and links, please go to http://www.healthychildren.org/English/news/Pages/Whats-the-Latest-with-the-Flu-A-Message-for-Caregivers-and-Teachers.aspx

 

 


Holiday Safety & Mental Health Tips
12-08-2014

The holidays are an exciting time of year for kids, and to help ensure they have a safe holiday season, here are some tips from the American Academy of Pediatrics (AAP). 

Trees

  • When purchasing an artificial tree, look for the label "Fire Resistant."
  • When purchasing a live tree, check for freshness. A fresh tree is green, needles are hard to pull from branches and needles do not break when bent between your fingers. The trunk butt of a fresh tree is sticky with resin, and when tapped on the ground, the tree should not lose many needles.
  • When setting up a tree at home, place it away from fireplaces, radiators or portable heaters. Place the tree out of the way of traffic and do not block doorways.
  • Cut a few inches off the trunk of your tree to expose the fresh wood. This allows for better water absorption and will help keep your tree from drying out and becoming a fire hazard.
  • Be sure to keep the stand filled with water, because heated rooms can dry live trees out rapidly. 

Lights

  • Check all tree lights (even if you've just purchased them) before hanging them on your tree. Make sure all the bulbs work and that there are no frayed wires, broken sockets or loose connections.
  • Never use electric lights on a metallic tree. The tree can become charged with electricity from faulty lights, and a person touching a branch could be electrocuted.
  • Some light stands may contain lead in the bulb sockets and wire coating, sometimes in high amounts. Make sure your lights are out of reach of young children who might try to mouth them, and wash your hands after handling them.
  • Before using lights outdoors, check labels to be sure they have been certified for outdoor use. To hold lights in place, string them through hooks or insulated staples, not nails or tacks. Never pull or tug lights to remove them.
  • Plug all outdoor electric decorations into circuits with ground fault circuit interrupters to avoid potential shocks.
  • Turn off all lights when you go to bed or leave the house. The lights could short out and start a fire.

Decorations

  • Use only non-combustible or flame-resistant materials to trim a tree. Choose tinsel or artificial icicles of plastic or nonleaded metals.
  • Never use lighted candles on a tree or near other evergreens. Always use non-flammable holders, and place candles where they will not be knocked over.
  • In homes with small children, take special care to avoid decorations that are sharp or breakable. Keep trimmings with small removable parts out of the reach of children to prevent them from swallowing or inhaling small pieces. Avoid trimmings that resemble candy or food that may tempt a young child to eat them.
  • Wear gloves to avoid eye and skin irritation while decorating with spun glass "angel hair." Follow container directions carefully to avoid lung irritation while decorating with artificial snow sprays.
  • Remove all wrapping papers, bags, paper, ribbons and bows from tree and fireplace areas after gifts are opened. These items can pose suffocation and choking hazards to a small child or can cause a fire if near flame. 
  • Keep potentially poisonous holiday plant decorations, including mistletoe berries, Jerusalem cherry, and holly berry, away from children.

Toy Safety

  • Select toys to suit the age, abilities, skills and interest level of the intended child. Toys too advanced may pose safety hazards for younger children.
  • Before buying a toy or allowing your child to play with a toy that he has received as a gift, read the instructions carefully.
  • To prevent both burns and electrical shocks, don’t give young children (under age 10) a toy that must be plugged into an electrical outlet. Instead, buy toys that are battery-operated.
  • Young children can choke on small parts contained in toys or games. Government regulations specify that toys for children under age three cannot have parts less than 1 1/4 inches in diameter and 2 1/4 inches long.
  • Children can have serious stomach and intestinal problems – including death -- after swallowing button batteries or magnets. In addition to toys, button batteries are often found in musical greeting cards, remote controls, hearing aids and other small electronics. Small, powerful magnets are present in many homes as part of building toy sets. Keep button batteries and magnets away from young children and call your health care provider immediately if your child swallows one.
  • Children can choke or suffocate on uninflated or broken balloons; do not allow children under age 8 to play with them.
  • Remove tags, strings, and ribbons from toys before giving them to young children.
  • Watch for pull toys with strings that are more than 12 inches in length. They could be a strangulation hazard for babies.
  • Parents should store toys in a designated location, such as on a shelf or in a toy chest, and keep older kids’ toys away from young children.

Food Safety

  • Bacteria are often present in raw foods. Fully cook meats and poultry, and thoroughly wash raw vegetables and fruits.
  • Be sure to keep hot liquids and food away from the edges of counters and tables, where they can be easily knocked over by a young child’s exploring hands. Be sure that young children cannot access microwave ovens.
  • Wash your hands frequently, and make sure your children do the same.
  • Never put a spoon used to taste food back into food without washing it.
  • Always keep raw foods and cooked foods separately, and use separate utensils when preparing them.
  • Always thaw meat in the refrigerator, never on the countertop.
  • Foods that require refrigeration should never be left at room temperature for more than two hours.                          

Happy Visiting

  • Clean up immediately after a holiday party. A toddler could rise early and choke on leftover food or come in contact with alcohol or tobacco.
  • Remember that the homes you visit may not be childproofed. Keep an eye out for danger spots like unlocked cabinets, unattended purses, accessible cleaning or laundry products, stairways, or hot radiators.
  • Keep a list with all of the important phone numbers you or a baby-sitter are likely to need in case of an emergency. Include the police and fire department, your pediatrician and the national Poison Help Line, 1-800-222-1222. Laminating the list will prevent it from being torn or damaged by accidental spills.
  • Always make sure your child rides in an appropriate car seat, booster seat, or seat belt. In cold weather, children in car seats should wear thin layers with a blanket over the top of the harness straps if needed, not a thick coat or snowsuit. Adults should buckle up too, and drivers should never be under the influence of alcohol or drugs.
  • Traveling, visiting family members, getting presents, shopping, etc., can all increase your child's stress levels. Trying to stick to your child's usual routines, including sleep schedules and timing of naps, can help you and your child enjoy the holidays and reduce stress.

Fireplaces

  • Before lighting any fire, remove all greens, boughs, papers, and other decorations from fireplace area. Check to see that the flue is open.
  • Use care with "fire salts," which produce colored flames when thrown on wood fires. They contain heavy metals that can cause intense gastrointestinal irritation and vomiting if eaten. Keep them away from children.
  • Do not burn gift wrap paper in the fireplace. A flash fire may result as wrappings ignite suddenly and burn intensely.
  • If a glass-fronted gas fireplace is used, keep children and others well away from it with a screen or gate. The glass doors can get hot enough to cause serious burns and stay hot long after the fire is out.

Holiday Mental Health Tips

  • Take care of yourselfJust like they say on the airplane, “In the event of an emergency, put your own oxygen mask on first, and then help children travelling with you to put theirs on.” Children respond to the emotional tone of their important adults, so managing your emotions successfully can help your children handle theirs better, too.
  • Make a plan to focus on one thing at a time. Try a few ideas from “mindfulness” as a strategy to balance the hustle and bustle of things like shopping, cooking, and family get-togethers during the holidays: stop and pay attention to what is happening at the moment, focus your attention on one thing about it, notice how you are feeling at the time, withhold immediate judgment, and instead be curious about the experience.
  • Give to othersMake a new holiday tradition to share your time with families who have less than you do, for example, if your child is old enough, encourage him or her to join you in volunteering to serve a holiday meal at your local food bank or shelter. Help your child write a letter to members of the armed forces stationed abroad who can’t be home with their own family during the holidays.
  • Keep routines the same. Stick to your child’s usual sleep and mealtime schedules when you can to reduce stress and help your child and you enjoy the holidays.
  • Keep your household rules in effect. Adults still have to pay the bills and kids still need to brush their teeth before bedtime​!
  • Teach the skills that children will need for the holidays in the weeks and months ahead. For example, if you plan to have a formal, sit-down dinner, practice in advance by having a formal sit-down dinner every Sunday night. 
  • Don’t feel pressured to “over-spend.” Think about making one or two gifts instead of buying everything. Help your child make a gift for his or her other parent, grandparents, or other important adults and friends. Chances are, those gifts will be the most treasured ones and will teach your child many important lessons that purchasing presents can’t.
  • Most important of all, enjoy the Holidays for what they are - time to enjoy with your family. So, be a family, do things together like sledding or playing board games, spend time visiting with relatives, neighbors and friends.​

 All information provided by HealthyChildren.org.  For additional information and links, please go to http://www.healthychildren.org/English/news/Pages/Holiday-Safety-Tips.aspx

Published

11/20/2014 12:00 AM

 


How to Buy Safe Toys
12-01-2014

How can I be sure I am buying toys that are safe for my child?

Children can have a lot of fun playing with their toys. However, it’s important to keep in mind that safety should always come first. Each year thousands of children are injured by toys. Read on to learn what to look for when buying toys and how a few simple ideas for safe use can often prevent injuries.

How to prevent injuries

Most injuries from toys are minor cuts, scrapes, and bruises. However, toys can cause serious injury or even death. This happens when toys are dangerous or used in the wrong way.

Tips for buying toys

Here are 10 tips to help you choose safe and appropriate toys for your child.

  1. Read the label. Warning labels give important information about how to use a toy and what ages the toy is safe for. Be sure to show your child how to use the toy the right way.
  2. Think LARGE. Make sure all toys and parts are larger than your child’s mouth to prevent choking.
  3. Avoid toys that shoot objects into the air. They can cause serious eye injuries or choking.
  4. Avoid toys that are loud to prevent damage to your child’s hearing.
  5. Look for stuffed toys that are well made. Make sure all the parts are on tight and seams and edges are secure. It should also be machine washable. Take off any loose ribbons or strings to avoid strangulation. Avoid toys that have small bean-like pellets or stuffing that can cause choking or suffocation if swallowed.
  6. Buy plastic toys that are sturdy. Toys made from thin plastic may break easily.
  7. Avoid toys with toxic materials that could cause poisoning. Make sure the label says “nontoxic.”
  8. Avoid hobby kits and chemistry sets for any child younger than 12 years. They can cause fires or explosions and may contain dangerous chemicals. Make sure your older child knows how to safely handle these kinds of toys.
  9. Electric toys should be “UL Approved.” Check the label to be sure.
  10. Be careful when buying crib toys. Strings or wires that hang in a crib should be kept short to avoid strangulation. Crib toys should be removed as soon as your child can push up on his hands and knees.

Gift ideas by age

Age recommendations on toys can be helpful because they offer guidelines on the following:

  • The safety of the toy (for example, if there any possible choking hazards)
  • The ability of a child to play with the toy
  • The ability of a child to understand how to use a toy
  • The needs and interests at various levels of a child’s development
  • Important information about recalled toys

One of the goals of the Consumer Product Safety Commission (CPSC) is to protect consumers and families from dangerous toys. It sets up rules and guidelines to ensure products are safe and issues recalls of products if a problem is found. Toys are recalled for various reasons including unsafe lead levels, choking or fire hazards, or other problems that make them dangerous. Toys that are recalled should be removed right away. If you think your child has been exposed to a toy containing lead, ask your child’s doctor about testing for elevated blood lead levels.

All information provided by HealthyChildren.org.  For additional information and links, please go to http://www.healthychildren.org/English/safety-prevention/at-home/Pages/How-to-Buy-Safe-Toys.aspx

 Last Updated  8/7/2013

Source

A Parent's Guide to Toy Safety (Copyright © 2008 American Academy of Pediatrics)

The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

 


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