Is rice cereal safe for your child?

A study conducted by researchers at Dartmouth published in JAMA Pediatrics found that infants who consume increased amounts of rice cereals and foods containing rice have higher levels of urinary arsenic. Arsenic exposure is associated with an increased risk of neurocognitive problems in children.

In light of these recent findings, what are parents to think?

The FDA has just proposed new guidelines on the allowable amounts of arsenic in rice cereal that is parallel to the level set by the European Commission (EC) for rice intended for the production of food for infants and young children. (The EC standard concerns the rice itself; the FDA’s proposed guidance sets a draft level for inorganic arsenic in infant rice cereal.) FDA testing found that the majority of infant rice cereal currently on the market either meets, or is close to, the proposed action level.

Why is rice higher in arsenic than other grains?

Arsenic is present naturally in soil and water, and fertilizers and pesticides contribute additional amounts. As rice plants grow, they take up arsenic more readily than other crops. A rice labeled as organic does not guarantee a low level of arsenic due to these natural sources.

What should parents feed their infants and children?

The American Academy of Pediatrics recommends that infants be exclusively breastfed for about six months, followed by continued breastfeeding as complementary foods are introduced. When a child is around six months, infant cereals can be gradually introduced. Rice cereal fortified with iron is a good source of nutrients, but it shouldn’t be the only source, and does not need to be the first source. Oat, barley and multigrain cereals are other options.

The FDA is also advising pregnant women to consume a variety of grains, in order to limit potential arsenic exposure to the developing fetus. Washing the rice prior to cooking also helps decrease the levels of arsenic, although this may also decrease the amounts of nutrients.

 

Natasha Polensek, M.D.
Director, Doernbecher Healthy Lifestyles Clinic
Clinical Associate Professor of Pediatrics
OHSU Doernbecher Children’s Hospital

 

Swimming in the NICU

The moment your child is admitted to the NICU, your life changes. Below, Megan explains how she stayed afloat in the NICU and shares some tips for other families who aren’t sure who or how to ask for help.

***

The birth of our youngest son on June 20, 2014, marked the beginning of a 3-month stay at OHSU Doernbecher Children’s Hospital. Although a prenatal diagnosis meant we were expecting a stay in the NICU, our family felt like we were thrown into the deep end of the proverbial pool.

As the mom, I felt like I was drowning in new medical terminologies, environments, demands, rhythms and uncertainties. It was sink or swim for the sake of our son. One fact I knew for certain: I needed help.

I slowly learned to ask for help, though it took longer in some areas than it did in others. At first, my voice was weak and sputtering, but with time, it became more clear and confident. No pamphlet or book could have prepared us for life in the NICU, but I hope my experiences will be helpful for other families learning to “swim” in the NICU.

Getting clarity from your care team

After experiencing my first set of “rounds” in the pod, I felt like I had more questions than answers – the medical staff seemed to be speaking a foreign language in an alternate universe and there were multiple unfamiliar monitors and equipment attached to my son.

On day 3, I realized my son’s nurse had been his nurse the day before. She was my first lifeline. I was discharged and able to spend some more time at his bedside. Nurse Mary slowly explained the equipment I was curious about, she talked through the different types of care she was providing and offered the postpartum practical tips for where to find pumping supplies and how to order lunch.

The next day when the doctors discussed my son’s case and post-surgery treatments, my mind was full of even more questions. Nurse Mary answered a lot of them and encouraged me to talk to the doctors for further clarification. I remember being surprised by the fact that we could actively participate in these conversations instead of letting them talk among themselves. My husband requested to talk to a doctor at the convenience of their schedule.

These initial conversations with the doctors laid a foundation for a mutual trust and respect with the end goal of improving our son’s health. The attending doctors were very knowledgeable with regard to diagnoses and treatments and the residents continually made time to answer our questions, even if it meant doing additional research or consulting their colleagues. They were eager to provide the help that we, as parents, needed.

Building your hospital team

While the doctors and nurses coordinated the care of my son, I soon realized that there were other hospital staff members who were available to care for patients’ family members. There is a social worker dedicated to the NICU patients and their families. The social worker can help with lodging, with postpartum care and with many other individualized need-based services.

In addition, a newly-formed hospital committee, which includes hospital staff and “graduate” parents, is dedicated to supporting NICU families at OHSU Doernbecher. The committee hosts activities near the unit and is also available to meet upon request. The committee is a great resource for those seeking conversation with and support from parents who have found themselves in similar circumstances. They understand what you’re going through, because they’ve been there.

Reaching out to volunteers

Weeks passed before I even considered leaving my son’s bedside vacant for an extended period of time during the day. I was “that mom” – the one who would have slept there if she could. Volunteers are often available to help on the unit – they provide an extra set of arms to hold your child if you need an afternoon away. Others serve families by taking pictures of the babies on unit and delivering printed copies back to the bedside. These volunteers delight in caring for the smallest lives at OHSU. Never hesitate to approach a volunteer and ask for help – that’s why they’re there!

Asking family and friends for help    

This last category of caregivers seemed to be the easiest to ask, but in the early days it’s hard to know what to ask! The moment your child is admitted to the NICU, your life seems to shift into crisis mode. Many friends and family generously offered to help – I’ll do anything I can, just name it! – but I wasn’t sure what I needed initially.

I found that offers to do very practical, simple tasks (bringing food, providing childcare for our older children, visiting to hold the baby at his bedside) were most helpful for us. Friends and family who were able to visit us on the unit were given a unique perspective on what life was really like with an infant in the hospital. Our visitors seemed to have an immediate compassion for our situation and they carried that into interactions after our child was discharged.

Simply being present by visiting was so helpful for us. We asked family to take our older children into their home for extended stays so we could focus our care on the hospitalized child. We asked those that were providing extended childcare for us to bring our kids to the hospital for a fun visit. We would take the kids to the playground at Doernbecher, go for a walk or ride the tram down for a treat at a nearby cafe. We asked other friends to come sit with our son so we could take a break away from the NICU and care for our older children for a day.

I quickly developed friendships with other NICU mamas who spent extended time on the unit. Sometimes, we would order meal trays at the same time so we could “have lunch” together or we’d escape the hospital for an hour or so to grab coffee or appetizers.

Our time spent together off of the unit were unforgettable. We could relate. We didn’t have to ask each other what it was like to have an infant in the NICU, because we already knew what it felt like. These “on unit” friendships provided a big help, because much like the pods in which we lived our lives, we didn’t feel isolated. We knew we weren’t alone. Often times, I found that family and friends helped buoy me up when I found myself sinking.

Every year, more than 5,000 babies in Oregon and Southwest Washington are born too soon. OHSU Doernbecher has joined thousands of teams across the country that support the March of Dimes‘ March for Babies. Interested in participating? Join Team OHSU/Doernbecher Tiny Feet!

Related reading
It’s a roller coast ride: One mom’s NICU experience
Once upon a time: Mae Lin’s Doernbecher story
A note of thanks from 8-year-old former NICU patient Elle

 

 

 

 

Preventing window falls: Tips to keep kids safe

Pediatricians often think of springtime as the beginning of “falling season.” Every year, 3,300 children younger than 6 fall from windows, according to the United States Consumer Product Safety Commission. Approximately eight of these falls will result in death.

In support of National Window Safety Week — April 3 to 9 — the Tom Sargent Safety Center at OHSU Doernbecher Children’s Hospital is sharing tips to prevent window falls:

  • Install it. Screens are not strong enough to prevent a child from falling. Installing window guards or stops is the best way to prevent window falls. Experts recommend leaving the guards and stops in place until children are 11 years old.
  • Move it. Prevent children from getting to windows by moving items they can climb on – including beds, dressers and shelves – away from windows.
  • Lock it. Keep windows locked. Only open the windows that children can’t reach. If you have double-hung windows, only open them from the top.
  • Teach it. Create a no-play zone by moving all toys and decorations away from windows. Teach children not to play in this area.

If a fall does occur: Don’t try to move your child; call 911 immediately.

“Sadly, we often think of spring as ‘falling season’ because the weather gets warmer, and people begin to open their windows. Children are curious by nature and can easily and quickly fall through an open window,” said Ben Hoffman, M.D., director of our Tom Sargent Safety Center. “Unfortunately, falls are the leading cause of injury hospitalization for children in the U.S. Parents and care providers should consider this and take necessary precautions to prevent potential falls. Using window stops and guards are an easy, cheap and very effective way to decrease the risk of serious injury.”

Ask about window safety toolkits at our Tom Sargent Safety Center (located just inside the OHSU Doernbecher lobby). For additional information about National Window Safety Week events and resources, visit ohsu.edu/childsafety or stopat4.com.

A day in the life of a Doernbecher doc

In her spare time, Dr. Guzman loves long-distance running. Here she is at the 2015 Paris International Marathon!

In her spare time, Dr. Guzman loves long-distance running. Here she is at the 2014 Paris International Marathon!

For the last 12 years, Dr. Judy Guzman has cared for OHSU Doernbecher patients with infectious diseases. She loves working with kids because of their optimism, and it’s safe to say our patients and families feel the same way about her. Affectionately known as “The Guz” among some patient families, Dr. Guzman is also involved in several projects aimed at decreasing hospitalized children’s risk of developing infections.

This Doctors Day, we sat down with Dr. Guzman to learn what an average Wednesday looks like for her.

***

6:00 a.m.: Wake up for a morning run around my neighborhood (although the recent Daylight Saving change has admittedly made me skip a few runs…)

7:00 to 8:00 a.m.: Get my kids ready for school. They’re old enough to make their own breakfasts at this point, so I’m just a supervisor now!

8:00 a.m.: Wave kids off to school. We’re lucky to live only three blocks from our school, so they can walk – rain or shine! Once they’re on their way, I drive up to Doernbecher.

Dr. Guzman and her amazing clinic team meeting with a sweet Doernbecher patient

Dr. Guzman and her amazing clinic team meeting with a sweet Doernbecher patient

9:00 a.m. to 12:30 p.m.: Wednesday morning clinic. I have the best clinic team ever!

12:30 p.m.: Lunch. Every Wednesday I have the kale Caesar salad from the Natural Food Store next to the OHSU gift shop. It’s my favorite!

1:00 p.m. to 5:30 p.m.: Various tasks, including patient care, research meetings and conference calls. Of course, there’s always some paperwork to do!

5:30 p.m.: Head home! I spend the rest of the evening making dinner, helping my kids with their homework – general household frenzy stuff!

 

Dr. Guzman with her family

Dr. Guzman with her family

 

Judy Guzman, D.O.
Associate Professor of Pediatrics, Division of Infectious Diseases
OHSU Doernbecher Children’s Hospital

 

 

Know a Doernbecher doctor you’d like to thank? Leave a comment below or email socialmedia@ohsu.edu, and we’ll be sure to pass along your note! 

Hemangiomas: What parents need to know

As their infant grows and matures, many parents will experience and express concern about birthmarks. Up to 20 percent of Caucasian babies will have vascular birthmarks. The most common type is the infantile hemangioma, also known as “strawberry hemangioma.”

Hemangiomas are benign vascular proliferations that tend to appear in the infant’s first week of life as a faint red stain or patch. Over the next several weeks to months, the hemangioma undergoes a rapid proliferation or growth phase. When the child is approximately 6-9 months, the hemangioma’s growth halts and is followed by a very slow involution or “shrinking” phase.

Approximately 10 percent of hemangiomas involute, or “disappear” by 1 year, 50 percent by 5 years and 90 percent by 9 years. Many will never completely disappear and can leave behind some residual changes in the skin and tissues. These are most troubling when located on one’s face or neck.

While we don’t know what causes hemangiomas, we do know that there are some risk factors for getting hemangiomas, including :

  • Caucasian race
  • Female gender
  • Prematurity
  • Low birth weight
  • Multiple gestation
  • Prenatal hypoxia (pre-eclampsia, placental abnormalities)
  • Advanced maternal age


What to know if your infant has a hemangioma
The rapid growth in hemangiomas occurs during the first 3-4 months of life in most babies; close observation is often suggested during this time to determine which lesions require treatment (e.g., those causing functional impairment or those with impending complications like ulceration, obstruction of the eye or breathing passages). Early treatment (as young as 4 weeks of age) is most effective in halting the growth of these birthmarks.

Learn more about birthmarks and get in touch with our Hemangioma and Vascular Birthmarks Clinic here.

Carol J. MacArthur, M.D.
Professor, Pediatric Otolaryngology – ENT
OHSU Doernbecher Children’s Hospital

 

 

 

The Talk: Let your kid’s questions be the guide

This article was written by Megan Haverman and originally appeared in the Portland Monthly 2016 Kids’ Health Annual magazine.

It’s inevitable. Maybe a curious 4-year-old inquires after the state of an obviously pregnant woman in the grocery aisle. Maybe a kid happens upon a racy scene on TV, or hears something from friends that requires explanation. This is the moment at which many parents balk: the beginning of the discussion of the bird and the bees.

Barbara Long, M.D., M.P.H., who’s worked as an adolescent doctor for more than 20 years, says these questions are often more benign than parents believe. “Sex is not a freak-out thing, but it tends to be perceived that way,” she says. “We worry about it! But if we’re matter-of-fact and use the right kind of language, it doesn’t have to be.”

The trick, according to Dr. Long, is to answer only what’s being asked; add more detail later, or upon further interrogation. “A baby comes from the mom” can easily expand into, “Mom pushes out the baby at the hospital.” Often, that might be enough. By giving the simplest answer, parents can maintain a developmentally appropriate conversation over time.

By 9 or 10 answers become more nuanced: “Mom has an egg and dad has sperm, and they get together and make a baby.” If a child asks how, then it’s time to break things down into penises and vaginas. While Dr. Long recommends using the correct words for each body part, she says it’s more important for parents to feel comfortable.

Parents can initiate conversation outside of the kitchen table to keep the discussion light: Dr. Long suggests using television, which often implies sexual activity, as a jumping-off point to talk about dating relationships, birth control or safe sex in the context of other people.

“I want to break down the myth that kids don’t want to talk to their parents about sex,” she says. “They want to talk, they don’t want to be talked at – there’s a big difference.” Parents can make it a two-way street by asking what their child thinks is happening, or how they feel about it.

A holistic approach to the conversation also helps kids to be in a better position when they’re teenagers. “We really just want our kids to make good decisions,” Dr. Long explains. “At 13 to 15, you’ve already done your work. They’re making decisions that are a reflection of their upbringing. That’s why the ongoing discussion is important.”

 

You’re not alone!

  • An online search for “talking to kids about sex” should lead to both helpful and personal tales.
  • Planned Parenthood offers tips for talking to children at any age about sexuality, plus a parents’ guide to Puberty 101.
  • A part of the National Campaign to Prevent Teen and Unplanned Pregnancy and aimed at older adolescents and young adults, Bedsider.org features a Guy’s Guide to birth control and a section on sexual myth-busting.

All tied up with latching

Nothing compares to the excitement of being a new parent. The bond between a mother and her baby starts to form soon after birth, and it happens in many ways. Mothers have to assist their newborns in basic functions, including sleeping and eating. So when breastfeeding does not go as smoothly as had been expected, it can cause significant frustration in new parents.

When discussing this issue, something that frequently comes up is whether or not a child could have a shortened tongue frenulum, also known as a “tongue tie.”

What is tongue tie?
We all have a frenulum underneath our tongue. As we develop in the uterus, our tongue starts out fused to the floor of our mouth. As we grow, the tongue is freed, except in the midline, where a small band of tissue remains – we call this the frenulum. The size of this band and the degree to which it restricts tongue movement can vary widely.  Studies show that up to 10 percent of the population can have this condition; however, it doesn’t always cause symptoms.

What problems can it cause?
Tongue tie has been associated with breastfeeding problems, including sore nipples, poor latch and poor weight gain. A quick procedure called a frenulotomy can be performed, and at least in some cases, can be helpful to improve breastfeeding. The procedure is not without risks, although they are fairly rare; these can include bleeding, infection, injury to surrounding saliva glands and recurrence of the tie due to scarring. It also doesn’t always work to fix all issues with breastfeeding.

Because this issue has not been researched as thoroughly as we would like, the degree to which your baby may improve with the procedure can be hard to determine.  Your Otolaryngologist will work with you to weigh the risks and benefits for your particular situation in deciding whether or not to proceed.

When does tongue tie need to be treated?
The procedure is reasonable to consider when there is significant pain with nursing that doesn’t improve with time, experience and improved latching technique. Additionally, poor weight gain in a child with a tight frenulum may prompt consideration of the procedure. A consultation with a lactation consultant can be invaluable in sorting out these issues.

Tongue tie can also be associated with speech problems.  These do not usually surface until later in childhood, often between 4-6 years of age, and affect only a minority of patients that are born with a tongue tie. For this reason, clipping the tongue in a baby solely to prevent future speech problems is not generally recommended.

Lourdes Quintanilla-Dieck, M.D.
Assistant Professor, Pediatric Otolaryngology – ENT
OHSU Doernbecher Children’s Hospital

 

 

Ericka King, M.D.
Assistant Professor, Pediatric Otolaryngology – ENT
OHSU Doernbecher Children’s Hospital

 

 

 

After baby: Supporting new moms when days are full of tears

This piece originally appeared on the KinderCare blog. It’s shared here with their permission. 

Most parents will name the day their baby arrived in the world as one of their very best days of their lives.

But what if mom doesn’t feel overwhelmed with joy? What if she finds herself crying a few times a day? What if she just can’t find the energy to get out of bed? And what if all of this makes her feel she’s failing as a mother?

“The fact is that most women have some worry and occasional weepiness after they have a baby,” says Dr. Nicole Harrington Cirino, who heads the Women’s Mental Health and Wellness division at the OHSU Center for Women’s Health.

There are very real reasons for the moodiness – beyond first-days-with-a-newborn exhaustion. Immediately after child birth, levels of hormones like estrogen and progesterone (which are 20 to 30 times greater than normal during pregnancy) drop precipitously. These dramatic shifts can have a profound impact on the chemical-messenger systems of the brain, which in turn can alter a new mother’s emotions, concentration, attention and response to stress. Fatigue, exhaustion, oversensitivity, loneliness and crying: These all can be typical responses to these hormonal changes.

The tricky part for a new mom who suddenly finds herself in tears is figuring out whether her reactions are normal, or if she may be exhibiting more serious symptoms associated with postpartum depression, anxiety, or other mood disorders. Doctors call these profound changes perinatal mood and anxiety disorders (or PMAD), and they are not uncommon. One in seven women will experience postpartum depression, or PPD, after their pregnancy.

Here’s how to take care of yourself, and support new mothers, daughters, and friends when they need it – and encourage them to reach out for support if necessary.

Prepare for the possibility

Women who have a history of depression or anxiety are more susceptible to postpartum depression or other mood disorder. Other risk factors include a strong family history of mental illness, an unstable relationship with the father of the baby, economic hardship, an unplanned or high-risk pregnancy, or twins or triplets. But even women without these risk factors may experience PMAD.

If you think you may be susceptible, get your support team in place. In those early months with a new baby, getting (close to) enough sleep, eating nutritious meals and taking (some) time to care for yourself can be powerful tools to guard against depression and mood disorders. Talk to your partner, parents, friends and in-laws about what help you might need – cooking meals, doing laundry, watching the baby while you shower – and what support they can give. Don’t be afraid to get specific!

Take note of your feelings

There is a difference, Cirino says, between “baby blues,” which peaks days 3 to 5 days after childbirth and resolves within one or two weeks, and more serious conditions. The baby blues is a milder form of depression.

“These women are still able to experience joy, and their mood recovers after hours or a day,” Cirino says. “But if a woman’s symptoms persist or worsen for more than two weeks or are severe enough to really interfere with her relationship with her baby, her partner or her ability to provide care for herself, then she may need more professional support.”

It can be difficult, in those sleep-deprived days, to keep track your feelings, so enlist your partner’s help, or jot down your feelings in your phone or on a calendar.

Talk about the changes you’re experiencing

Don’t sit alone with your thoughts. Cirino recommends talking about it with a trusted friend, partner, obstetrician or primary care doctor. Speaking up, she says, can often be the hardest part.

“Some women who experience this often are successful women who are trying to do everything well and can’t admit they may be struggling and need help,” she says. “They may have no history of mental illness and do not understand it, so they blame themselves and what they think are weaknesses as a mom.”

Fortunately, we’ve become a lot more comfortable talking about PPD, partly thanks to celebrity moms like Hayden Panettiere who experienced overwhelming postpartum depression. “It’s really painful and it’s really scary and women need a lot of support,” Panettiere told “People” magazine.

Remember that depression is only one possibility

Not all symptoms show up as depression. According to Cirino, many women have heightened anxiety after pregnancy and birth. This can manifest in physical symptoms of anxiety like heart racing, shortness of breath, tremors, feelings of choking, and insomnia. Other women have obsessive thoughts about cleanliness, safety, their infant being harmed or other worries that they just can’t get out of their head. If you’re not feeling right after giving birth, but it doesn’t seem like “depression,” don’t hesitate to reach out to your doctor or other health care professional you trust.

How to help a new mom in your life who is struggling 

“Be supportive and listen without judging. Make sure moms get sleep and breaks from childcare to eat, exercise, socialize and have time to care for themselves,” says Cirino.

“Partners can also play the vital role of helping moms arrange mental health appointments and follow through on treatment plans, since sometimes it is hard to initiate and follow through on tasks when you are depressed or anxious.” Most importantly, “Reassure them of how much they are loved and help them be in contact with others who care for them and love them.”

 

The Director of Women’s Mental Health and Wellness at OHSU, Dr. Nicole Cirino was trained as a reproductive psychiatrist and has specialized in working with mental health issues experienced exclusively by women across their reproductive life cycle. Dr. Cirino has worked extensively with women and their families who experience perinatal mood and anxiety symptoms for the past 10 years.

 

Volunteer spotlight: Meet Gloria

The OHSU Doernbecher lobby is a busy place. It’s where visitors and employees go to fuel up on coffee, where colleagues convene, where students study and, often, where families and friends meet to talk, to hope, to cry, to get a moment of peace.

If you’ve been in our lobby in the last 11 years, you might already know volunteer Gloria Libby. She sits, focused, at the piano, where she plays music for the benefit of all who pass through our hospital. Unless you happen to spot Gloria’s white cane, you’d never know she’s unable to see sheet music or even the piano keys (though she does have the ability to detect light and shadows). When she was just 2 weeks old, a cerebral hemorrhage left Gloria blind.

 

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We sat down with Gloria to ask her a few questions about the healing power of music at Doernbecher.

How long have you been playing the piano?
Well, my mother says I started when I was 5, but I don’t remember playing until I was 6 or 7 years old. I went to residential schools for the blind all 12 years of my education. That’s where I took piano lessons!

What kind of music do you enjoy?
I’m classically trained, so I like to simplify and play some classics. I play a lot of hymns and I like to play oldies – songs for baby boomers and before. I also love listening to Celtic music.

Why did you choose to volunteer at Doernbecher?
[I was already connected to OHSU in a way because] my husband had a job in employee health at OHSU. Initially I reached out because I wanted to volunteer to rock babies in the NICU. I ended up playing the piano at Doernbecher instead and have been doing so for about 11 years now – it’s a special way to reach out to people. I also play at church and at the retirement home where I live.

What’s your favorite part about volunteering at Doernbecher?
I love the people here. I kind of like to hide behind the piano a bit, but I can still be social!  I especially like it when parents bring children to me to say hello. And, of course, I love visits from the animal-assisted therapy teams, including Sallie and Beau!

How do you think music helps calm and heal Doernbecher’s passersby?
I was a certified Music Therapist, and what I’m doing at Doernbecher just feels right. I think there’s a lot of unease at any hospital. There’s trauma going on; there’s life and death going on. Students, too, are learning to face these issues and I think music really helps.

***

Thank you for sharing your time and your music with us, Gloria!

A message from the Oregon Poison Center

In light of the recent arsenic and cadmium exposures in Southeast Portland, the Oregon Poison Center has the following message: The Oregon Department of Environmental Quality (DEQ) and the Oregon Health Authority (OHA) are working around the clock to respond to these exposures.

We are urging concerned citizens to keep abreast with the latest information from the DEQ and the OHA:
Click here to view the DEQ metal emissions website
Click here to view the OHA metal emissions website

The Oregon Poison Center is part of a multiagency collaboration to respond to these exposures. Our toxicology experts provide medical advice to health care providers and the public. Our hotline number is 1-800-222-1222.

Finally, we urge the public to follow our social media channels for the latest information from health authorities:
Follow the Poison Center of Oregon, Alaska and Guam on Facebook
Follow the Oregon Poison Center (@ORpoisoncenter) on Twitter

Additional coverage
“‘Should I get tested for arsenic or cadmium?’ – a doctor responds” via the Portland Mercury
 “Air at SE Portland schools to be tested Friday after toxins detected” via KGW
“Cadmium, arsenic in SE Portland air found 4 months ago” via KOIN

Questions? Please leave a comment below and we’ll do our best to get you an answer.

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