Vomiting and Diarrhea (AKA Gastroenteritis)

Tonight, I was enjoying a kid-friendly dinner with my boys, when I looked up just in time to see my oldest holding his stomach, with terror in his eyes. I quickly grabbed the little one and a tray, but was not fast enough to catch all the vomit the ensued. While trying to simultaneously calm both of my boys and clean up the mess, a very friendly waitress brought over a Sprite. My sweet boy wanted to take a drink, but I quickly told her to take it away. Instead, I cleaned up, ordered a Gatorade to go and started my 7 step program to taking care of a child with vomiting (and the diarrhea most likely to follow).

1) Get out a big bucket and towel
2) Wait 20-30 minutes before giving anything to drink
3) Start VERY slowly with drinking. Babies and toddlers should get 1 teaspoon (5 ml) of Pedialyte every 5 -10 minutes for 30-60 minutes. Older children can have sips every 5- 10 minutes of water or Gatorade. Next I try Popsicles - Pedialyte pops for babies and toddlers. You can also freeze Gatorade or even give ice cubes.
4) Wait until your child asks for food, then start with bland, easy to clean up foods. I like bread, crackers, soup. Give them only small amounts at a time.
5) Wait for the diarrhea to start (could be right away or 3 days from now). When the vomiting has stopped and the diarrhea has started, stop giving Pedialyte and do not give juice. This will make the diarrhea worse. You can let them eat whatever they want, but foods like bread, bananas, rice, noodles (like the BRAT diet) can help make the poop more solid. I also like to add yogurt (especially live-active culture) to the regimen.
6) Start a Probiotic. Several are available over the counter. I like Culturelle, but any brand will work. This will help your child re-establish normal gut bacteria and shorten the duration of diarrhea.
7) Wash hands and surfaces frequently!

If you child has persistent vomiting and can not tolerate any fluids for 3-4 hours in a younger child or 5-6 hours in an older child and they have signs of dehydration, like extreme fatigue, dry eyes (no tears with crying), dry mouth, dark urine or no urine they need to be seen by a pediatrician. There are anti-nausea medications available for children, though most do not need them. The majority of viral gastroenteritis illnesses last 1-3 days (if your child is immunized against Rotavirus), but children can continue to have diarrhea and a few episodes of vomiting daily for several more days. Some children develop an intolerance to milk for 1-2 weeks after a bout with viral gastroenteritis, this can lead to continued symptoms when your child eats or drinks milk products. Children tend to have upper abdominal pain with vomiting, but this should improve when the vomiting stops.

Signs that it is not gastroenteritis and your child needs to see a pediatrician:
1) Severe lower abdominal pain - especially on the right side
2) Fever and vomiting, without diarrhea after 2-3 days
3) Cough associated with vomiting
4) Vomiting with any urinary symptoms - especially pain while peeing
5) Vomiting bile - not yellow stomach acid, but dark green, disgusting vomit
6) Vomiting blood or material that looks like coffee grounds
7) Pooping blood or mucous

At bedtime, I held my little boy, while he held his towel and puke bowl. For now, he is sleeping and I hope that we are done with puke in our household for the night!

Heather Joyce, MD

Focus on Overuse Injuries in Kids: Stress Fractures

Stress fractures can be a scary diagnosis, because it is often a season ending injury, which is difficult for a young athlete to handle.  It is rare for stress fractures to occur before the teenage years, but it can happen if a young child is over-training.

Most commonly stress fractures in kids occur in the lower extremities.  There is not a threshold for how many hours a week a child must train for a stress fracture to occur, but typically they occur in young athletes doing weight-bearing activity for more than about 10-15 hours a week.  Sometimes there is an underlying metabolic or nutritional problem that makes an athlete more prone to a stress fracture (such as low calcium intake).  Also, young females who are underweight and have irregular menses because of over-training are at especially high risk of stress fractures.

A stress fracture can also progress to a complete fracture or break if not treated appropriately.  Often times they are misdiagnosed as muscle strains, but should be suspected if a child has pain with regular walking or is limping.

Treating stress fractures usually does not require an operation, but does generally require a long period of rest.  For example, a stress fracture in the femur can take months to heal, while a stress fracture in the inside part of the shin may only take a few weeks.  Some stress fractures don't heal well on their own and require surgery (for instance, the front part of the shin and the hip).  After a stress fracture heals it is important to gradually return to playing sports, and physical therapy may be required in the meantime to help with flexibility and muscle strengthening.

If your child trains many hours a week at his or her sport, it is crucial that they have days of rest during the peak training and also weeks of rest during the off season.  Also, make sure that your child has an adequate intake of calcium in his or her diet.  It is especially important that adolescent females maintain an appropriate body weight and regular periods to prevent stress fractures from occurring.

Ask your pediatrician if you are concerned that your child may have a stress fracture - further studies are necessary to make an accurate diagnosis and consultation with a sports medicine doctor is helpful.  A stress fracture is usually not visible on an x-ray and often another study is needed.  MRI is shown to be the best study for detecting stress fractures even if they have only just developed (with the exception of low back stress fractures where bone scan is used).  Regardless, it is important to know that stress fractures do occur in kids, especially in teenagers.

Rachel Brewer, MD

Fever Phobia

The first thoughts that go through my mind when my child has a high fever are the same as any parents; my baby looks horrible! Breathing fast and just lying there, he must be really sick. Then my pediatrician brain kicks in and I remember that fever is our body's best way of fighting off infection; changing the body temperature helps to kill the invading virus or bacteria. Fever is defined as rectal temperature greater than 100.4 F, but most physicians agree that the height of the temperature is not the most important symptom nor can it predict their illness (viral versus bacterial). Children tend to reach much higher body temerpature than adults, even with the same illness.  Most children look miserable when they have a high fever; flush, breathing fast (panting), with a fast heat rate and low energy. They feel BAD! So, our job as parents is to make them feel better and to make sure that they don't feel bad when their temperature goes down. The only exception to this rule is when you have an infant under the age of 3 months with a temperature over 100.4 F - they need to be evaluated by a doctor immediately

The best ways to reduce fever and make children feel better are:

1.     Ibuprofen or acetaminophen. You will hear many different opinions on how to give these medications. My personal preference to to pick one and give it as directed by your pediatrician, then use the other when your child has a fever or feels badly in between doses. Never give ibuprofen to infants under 6 months or aspirin to a child under 18 years. 

2.     Take your child's clothes off and place a thin, cotton blanket over them. Remember that your child's temperature will go up when wrapped in blankets. 

3.     Put them in a lukewarm bath - the temperature of the water should be normal body temperature (98.6 F), so it should not feel warm or cold to your wrist. Do not give a cold bath, ice bath, or alcohol rub, this will cause the child to shiver and it will raise the body temperature.

The most important parts of fever are the associated symptoms and the length of time it persists. Most fevers in children are from viral infections and do not last much longer than 3-5 days. Fever is rarely an emergency, but there are times when you will want to take your child to see a pediatrician. 

1.     Fever that lasts longer than 3 days

2.     Difficulty breathing, especially with wheezing, barking cough, or grunting

3.     Fever with persistent vomiting or signs of dehydration 

4.     Fever with urinary tract symptoms - pain with urination, accidents in a potty trained child, peeing more or less than usual

5.     Fever and headache, neck stiffness, or a rash that looks like bruises or "blood" dots 

6.     Fever without common viral symptoms - that means no congestion, runny nose, cough, vomiting, diarrhea

7.     Fever with abdominal pain in the right lower side 

I know that fever can be scary. No matter how much reassurance I give, parents tell me that they are still worried that their child has a serious bacterial infection, will get brain damage from high fever, or have a seizure. It is a parent's job to worry so let me state the facts: brain damage does not occur with high fever produced by the body due to an illness and febrile seizures (fever seizures) occur with changes in temperature and not specifically with high fever. If your child is going to have a febrile seizure, there is nothing you or a physician can do to keep it from occurring.

Children with serious bacterial illnesses do not look good when their temperature is normal. Treat your child's symptoms and not the fever – make them comfortable and know that if your child still looks ill when their fever is gone, that is the time to seek immediate medical attention. As always, it is always best to use your parental "gut" feeling, because you know your child best and no one will question you for seeking medical care if you are worried about your child.

---

Heather Joyce, MD

Focus on Overuse Injuries in Kids: Apophysitis

I wanted to retouch on an earlier topic regarding overuse injuries and focus on specific types in my next few posts.  As briefly discussed before, apophysitis is one of the most common types of overuse injuries in children.  Here’s a more in depth focus of what apophysitis is, where in the body apophysitis is most common, and how it is treated.

What is an apophysis?  An apophysis is a growth plate that provides a point for a muscle to attach.

What is apophysitis?  Apophysitis is due to chronic traction of a tendon at its origin or insertion.  The growth cartilage of the apophysis is the weak link in the muscle-tendon unit, and is prone to injury from repetitive activity.  Continuous stress at the apophyseal site leads to local swelling and pain.  It is most common in kids in elementary to high school age (when they start playing sports).

What are the most common sites of apophysitis?  The knee is the most common site of apophysitis in kids and is otherwise known as Osgood-Schlatter’s disease.  Other common sites are the heel (Sever’s disease), the lower part of the kneecap (Sinding-Larsen-Johansson disease), the outer side of the foot (Iselin’s disease), and the elbow (Little League elbow).  There are also several places on the pelvis where muscles attach, so apophysitis can occur in a handful of sites.  Soccer players, runners, and sprinters are especially prone to developing apophysitis in the pelvis (which usually presents as hip or groin pain). 

How are specific types of apophysitis treated?  All types of apophysitis are treated with activity modification (rest!), anti-inflammatories (like ibuprofen), ice, and potentially physical therapy depending on the severity.  Children with Osgood-Schlatter’s disease may benefit from a knee strap or knee pad depending on the sport, children with Sever’s disease can be treated with heel cups, and children with Iselin’s disease can be treated with a lace-up ankle brace or lateral heel wedge.

Is there a way to prevent apophysitis from happening?  Just like any overuse injury, it can be prevented with appropriate rest from activity, stretching, and using the right equipment for the specific sport.  However, some kids are more prone to developing apophysitis based on such things like muscle weakness or imbalance, and his or her running gait.  Such things can be evaluated and treated with physical therapy. 

It is not always easy to determine how long it takes for a type of apophysitis to completely resolve.  Some kids can heal in a few days while others can take weeks to months (even with the appropriate treatment).  Rest and activity modification is key to helping apophysitis resolve more quickly.

Rachel Brewer, MD

RSV (Respiratory Syncytial Virus)

As I sit at work in the ER at 3 am after a night up with my own baby coughing and seeing multiple children with bronchiolitis, RSV sits heavily on my mind.  I sent all of the children that I treated in the ER home tonight with the same advice that I use for my own children, but no "magic" cure. I tell my patients, truthfully, that if I had a cure to the common cold, I would happily give it out (and use it myself).   

RSV is the most well known virus that causes bronchiolitis, which is congestion, runny nose, cough, along with inflammation in the lungs - I liken it to bronchitis in adults. Most people with RSV (babies and adults) get a bad cold, with LOTS of snot! When the snot gets down into the lungs, it causes plugging and inflammation. Some children have fever with their respiratory symptoms. The babies that are most affected have labored breathing and wheezing with their illness. Children most likely to have more severe symptoms are premature infants, young infants (less than 3 months), children with heart disease and children with a predisposition to asthma. Older children with known asthma can have a severe asthma attack with this virus.

Currenlty, the best treatments that we have are symptomatic (meaning there is no cure with a medicine). In infants and toddlers this means nasal saline with frequent suctioning, using a cool mist humidifier, and encouraging fluids (breastmilk, formula, milk, pedialyte or popsicles) - remember that most childhood illnesses come with diarrhea, so be stingy with the juice! Acetaminophen or Ibuprofen for fever and fussiness.

Other treatments that may be used after seeing your pediatrician:
- Deep nasal suctioning (only at the doctor's office or hospital). Remember the cause of the difficulty breathing and drinking...snot. This treatment is just as it sounds, using a long tube to suck out all the snot from the back of the nose and throat.
- Albuterol breathing treatments. Usually this is attempted for wheezing. It may not work, but it is worth a try.
- Antibiotics. Bronchiolitis is caused by a virus. Antibiotics will not treat the symptoms. However, children may have a bacterial ear infection or pneumonia along with their illness and some phyciains choose to treat these with antibiotics.

Children who need to be seen by a physician have:
- Labored breathing (chest or tummy moving in and out with each breath), fast breathing (>40-60 breaths per minute, depending on the age of your child), grunting or wheezing noises, or pauses in breathing for greater than 10 seconds for young infants
- Decrease in fluid intake. Many children who are sick refuse to eat, but they need to drink enough to have 2-4 wet diapers per day.
- Fever for longer than 3 days, fever that starts after the illness has improved, or fever in any infant younger than 3 months old.

Children sometimes need to be admitted to the hospital, if they are not getting enough oxygen, having difficulty breathing not relieved by nasal suctioning or albuterol, or if they are dehydrated. Most children, however, will stay home with symptomatic care from their loving (and tired) parents. Symptoms usually last 3-5 days, but coughing and wheezing may go one for 2-3 weeks after a severe bought with RSV.

As I write this, I am feeling very thankful that so far, neither of my children have required anything more than some extra love, nose suctioning, and ibuprofen for their wintertime illnesses (and we have had MANY), but we have 2-3 months left of RSV and Influenza season this year and many more years to come...

Heather Joyce, MD

What the Heck is a Growth Plate?

Children are not just “little adults” when it comes to examining their bones and joints.  The fact that they are in such a rapid period of growth makes their musculoskeletal system extremely unique.  You may have heard your pediatrician talk about your child’s growth plates in their bones, but here’s an explanation of what they are, why they are important, and common injuries.

What is a growth plate?  The growth plate (also known as the physis) is the soft part and area of growing tissue near the ends of the long bones in children and adolescents.  The important thing to remember is that because of their soft nature, growth plates are extremely vulnerable to injury, and are weaker than the surrounding tendons and ligaments.  The opposite is true in adults – once a growth plate closes, the bone is stronger than the surrounding tendons and ligaments. 

When do growth plates go close?  Not all growth plates in the body close at the same time.  However, growth plates are all closed at skeletal maturity, which means that a person’s growth is complete.  For women this means after they begin their menses (about 14-17 years), and for men this occurs at about 18-22 years.  Just prior to puberty, most growth plates increase their rate of contribution to growth.  Girls tend to reach their peak growth at around 13-14, while boys are slight later (around 14-15). 

What are growth plate fractures?  A fracture is the same as a break.  Just like any other part of the bone, the growth plate can sustain a fracture.  And because the growth plate is soft and weak, it is more susceptible to fracture.  A fracture can be just through the growth plate, or can be through both the growth plate and other parts of the bone at the same time.  Simple growth plate fractures cannot be seen on an x-ray because the growth plate is not calcified. 

How are growth plate fractures treated?  Growth plate fractures are treated like any other fracture – with immobilization and rest.  Your doctor will likely get follow-up x-rays as well to determine the fracture is healing appropriately. 

What other common growth plate injuries are there?  Overuse injuries involving growth plates attached to tendons are also very common, and is otherwise known as apophysitis (as discussed in an earlier post).  Common sites of apophysitis are the knee (Osgood-Schlatter’s disease), the elbow (Little League elbow), and the heel (Sever’s disease).

Kids don’t sprain stuff.  Because growth plates are the weakest part of joints in kids, it is more likely for your child to sustain an injury to the growth plate before he or she sustains a sprain to the ligament of a joint like the wrist or ankle. 

As a parent, it is usually clear if a child injures a growth plate – he or she will favor the involved joint and complain of pain.   Take note if your child complains of pain after a fall or injury and remember that there is a high likelihood that the growth plate is involved.

Rachel Brewer, MD

A Dad's Guide To Healthcare

Guest blogger with no expertise or medical training of any kind! 

Time to come clean:

I defer all health-related decisions about the kids to my wife (Heather Joyce, MD). OK, full disclosure, she kinda manages my health too...and the dog's. Let's have a conversation about this:

You: "But Ryan, aren't you married to a pediatrician who is way smarter than you? It makes sense that she's in charge of the health stuff"

Me: "For sure. But how many dads out there are the family's healthcare managers? You don't actually have to answer, but seriously, how many? Huh? Speak Louder! I CAN'T HEAR YOU! "

You: "Dude, back off.  You're freakin' me out."

Me: [nodding somberly]. "I know, I know.  I'm just so passionate about avoiding responsibility that it just gets the best of me sometimes."

The answer is very few.  Dads manage the satellite TV subscription and lawn maintenance, but generally have no clue which vaccinations are due during the next check-up. I don't even know when the next check-up is supposed to be. Lets all agree that in this country Moms are the primary family healthcare managers. Ok, agreed. But is there anything wrong with that?  

In corporate America I quickly learned that every task needs a single responsible party. That person can delegate parts of  the job, but ultimately their derriere is on the line.  It makes sense at work and I think it makes sense at home. It is particularly nice for me because I came blame Heather when something goes wrong.  But seriously, there are times when we disagree (thank goodness we've never dealt with anything major).  For example:

• Is it better to deploy the dreaded nose sucker on the snotty/coughing boy at 3 am, or just rock him back to sleep?  
• Is it better to hammer the kids with Motrin and Benadryl for their winter colds, or just let them rest and get better naturally? 
• Should we risk anesthesia to get him ear tubes, or just keep dealing with the ear infections?

Based on Heather's first post in this blog, you can guess that we (she) almost always choose to intervene. Here's my guide for dads on how/when to be involved broken down in to 4 simple categories. Again, I have no expertise except for being a Dad of two boys with excessively runny noses.  

1. Simple stuff  (e.g. ibuprofen and nose suckers). Answer: Let her decide. You can pitch in by physically restraining little Buster when it's time to suck the snots out.

2. Minor Stuff with actual risks (e.g. surgery for tonsils or ear tubes) Answer: Google it (be wary of internet quacks), ask questions, offer your sincere opinion, then let her decide. 

3. Major Stuff with actual risks (e.g. treatment plan for a serious illness like Kawasaki disease). Answer: Ask LOTS of questions, Google, get second opinions and decide together. Also, dads can start a personal health record on the internet; many hospitals and health plans offer free services online. Oh, What's that you say? You've never heard of Kawasaki Disease? Like I said, Google it.  

4. Hot-button stuff that the media and Hollywood make very confusing (e.g. Vaccinations). Answer: this guest blogger has some strong opinions on vaccinations, but you should defer to your resident physician bloggers for actual medical advice on these subjects.

Thanks for reading and get those nose suckers ready cause its RSV season! 

Growing Pains - They are for Real

Have you ever wondered if growing pains actually exist?  Growing pains is an actual diagnosis that occurs in almost half of kids.  However, not all leg pain in kids is growing pains, and it is important to understand when to talk to your pediatrician if your child experiences lower extremity pain.

Growing pains almost never occur in the arms, and are most commonly felt in the lower legs (in the shin area), but can also be felt in the thigh area.  They are nearly always on both sides.  The pain experienced with growing pains typically occurs at night after a long day of playing or activity.  Pain can vary from mild to severe.  It is sometimes difficult for kids to localize the pain, but growing pains are not felt in joints.  Growing pains typically occur between the ages of 3-7.  

The cause is unknown, and the name "growing pains" is actually a misnomer.  These pains are not associated with rapid growth, and theories of whey they occur include vascular perfusion problems, tiredness, or psychological problems.

Treatment for growing pains includes massage, heat, or medicine (Tylenol or anti-inflammatories like ibuprofen).  Further treatment like physical therapy or bracing is not needed. Experiencing growing pains as a child will not predispose your child to future joint pain or problems. 

The important thing is to not assume that any leg pain that your child experiences is “just growing pains.”  Definite “red flags” that your child’s pain is outside of the realm of growing pains includes morning pain, joint swelling/stiffness, back pain, limping, unusual tiredness, or pain that occurs every night or pain that is worsening and/or severe.  These symptoms can be indicative of more severe problems like arthritis or other joint problems.  Talk to your pediatrician if your child exhibits any symptoms not typically associated with growing pains.

Rachel Brewer, MD

The Itch That Scratches and Scratches and Scratches....Eczema (Atopic Dermatitis)

For any of you that have children with eczema, you know what I am talking about. Kids can't help but scratch when they have an itch, and scratching ALWAYS leads to more itching! Eczema can range from dry, scaly skin to red, open, painful skin. It is sometimes associated with allergies and asthma (allergic triad). All forms of eczema have the same problem, there is a breakdown in the body's main protective organ - the skin. Babies tend to have eczema all over their bodies, which frequently spares the diaper area (sitting in a wet diaper does have some benefits!). Older children can have it all over their bodies, but classically they get it on the backs of their elbows and knees. You can find "magic" remedies for dry skin and eczema all in the drug stores and internet, but usually you can solve the problem with products you may already have around the house. The first step to treating eczema is to think of every product that touches your child's skin...I know, not an easy task. These products usually include (but are not limited to) detergents, fabric softeners, drier sheets, lotions, soaps, bubble bath, wet wipes, sanitizer wipes and gels, sun screen, saliva (drool) and foods. Got them?

Next:

1. Remember all of those products that touches your child's skin...stop them. I know you can't stop food and drool from touching your child's skin, but you can put a protective barrier ointment on the skin before he/she eats. 
2. Use only dye free and fragrance free detergent, without fabric softener or drier sheets. They may smell and feel good, but those products stick to clothes and sheets, then your child's skin.
3. Use only Sensitive Bar Soap. I prefer Dove or the generic alternative. Liquid soap is easier to use and feels nicer, but the chemicals that are used to make the soap into a liquid can irritate skin, even the sensitive versions. 
4. Apply an ointment moisturizer several times per day. I prefer Vaseline (petroleum jelly) because it is cheaper, but Aquaphor and several other companies make an ointment moisturizer that has petroleum as the main ingredient. Lotions feel and "absorb" into the skin better, but they do not form a barrier for the skin, which kids with eczema need. They can also burn when applied to irritated skin. One way that I have found to keep the petroleum jelly on your child's skin and off the furniture is to apply a thick layer and put a cotton one-piece pajama outfit on (dye-free if possible). For older kids, you can use cotton pajamas with cotton socks. If you or your child can not deal with the greasiness of petroleum jelly, then mineral oil can be used as an alternative (most formulations are petrolatum jelly in a liquid form). 

These recommendations will help mild to moderate eczema, but if your child has very red, irritated skin, they may need a steroid ointment. If this is the case, you need to take your child into the pediatrician for further recommendations and a possible prescription. There are also prescription medications that help prevent flare-ups, to be used when your child's skin is clear. A newer treatment that has been used with success in children with moderate to severe eczema, to discuss with your pediatrician, is bleach baths (1/2 cup of bleach per tub), used 1-2 times per week. This is used to help decrease the bacteria living on the skin and prevent infection. It sounds weird, but it is actually similar to swimming in a public pool. This treatment needs to be used with caution in children with asthma, because the chlorine can cause wheezing. Of course, petroleum jelly needs to be applied after the bath, to prevent the skin from drying out. If itching is a major problem, then talk to your pediatrician about using an antihistamine (like Benadryl). 

So, stop using the salve that Aunt Mary brought back from the "old country" and start using easy, everyday products to stop the itching! 

Heather Joyce, MD

Is In-Toeing in Kids Normal?

In-toeing, commonly referred to as “pigeon-toed,” means that your child walks and runs with his or her feet pointed inward.  This is usually noticeably soon after a child learns how to walk.  In the overwhelming majority of children, in-toeing will correct itself over the course of several years. Three conditions most often lead to in-toeing:

1.  Flexible hips (femoral anteversion):  This is the most common cause of in-toeing in children and is perfectly normal.  Flexible hips causes both the knees and feet to point inward – you’ll notice that kids with such flexibility can sit in a “W” position on the floor.  As children age, their hips tighten up and their in-toeing resolves.  This generally occurs by puberty (so be patient).  In-toeing itself does not slow a child down or cause them to fall or trip more than other children.  This condition uses to be treated with splints or shoes with a bar connected between them – these treatments do not help and can actually be detrimental.

2.  Bowed legs (tibial torsion):  This occurs when a child’s leg twists inward, which is normal when a child is an infant.  As a child grows older, his or her legs should gradually rotate to align properly.  This condition almost always improves without treatment, and usually before school age.  Splints, shoes, and physical therapy do not help.  Surgery is rarely performed unless the torsion does not resolve by about 10 years of age and it causes significant walking problems.

3.  Hooked foot (metatarsus adductus):  This condition is when a child’s foot bends inward from the middle part of the foot to the toes (not to be confused with a clubfoot, where the foot is rotated internally at the ankle).  This condition usually improves by itself over the first 4-6 months of life.  Babies older than 6 months with a severe deformity or a rigid hooked foot may be treated with casting.  Surgery is rarely required. 

Talk to your child’s pediatrician if you are concerned about your child’s in-toeing.  However, a referral to an orthopedist is not necessarily needed for the reasons described above.

Rachel Brewer, MD