In honor of  Father’s Day, we would love to hear your anecdotes of any “Doctor Dad” moments your children have experienced.  Tell us about how your child’s dad or any father figure in your child’s life helped your child through a tough time, an illness, or an injury. Send us your anecdotes to twopedsinapod@gmail.com by June 4 and we will include the top stories in our Father’s Day post. 

Thank you in advance,

Drs. Kardos and Lai   

This Mother’s Day we bring you definitions inspired by our children and our patients. Don’t think we’ll out-hip Urban Dictionary, but we’re moms…. by definition we are not hip. Enjoy your day.

Sleep walker: the daytime state of a new mom.

Sweater: a garment worn by a child when his mother feels cold.

Displacement:  a vacation with toddlers.

Sick: something moms are not allowed to become.

WOW: MOM upside-down.

Mommometer: a mom’s hand on a feverish forehead.

One zillion: number of times a mom says “wash your hands” to her children over the course of their childhoods.

Yesterday: when the sports/camp/school field trip form was due.
Today: when the child hands the mom the sports/camp/school field trip form.

Working mother: Every Mom

Water torture: a grade-school son’s interpretation of a mom’s announcement of “shower night.”

Boomerang: a mom’s realization that her child is acting like she did at the same age.

Happy Mother’s Day from your two Pediatrician Moms,

Julie Kardos, MD and Naline Lai, MD

©2013 Two Peds in a Pod®

A mom recently wrote to us: What are your thoughts on Baby-Led Weaning?

In Baby-Led Weaning, parents skip giving infants pureed foods and encourage their babies to self-feed whole foods. While there‘s little research on the merits of this method of infant feeding, there are few studies demonstrating the superiority of ANY particular method of introducing solid (complementary) food to infants over another.

It is acknowledged that even though a sequence of foods is outlined, that the sequence is a consensus not based on evidence. As a matter of fact, the old sequence is already changing in that meats to provide zinc and iron are encouraged sooner than later especially in breast-fed infants, says Chair of the American Academy of Pediatrics committee on nutrition, Dr. Jatinder Bhatia.

Here are our thoughts specifically about Baby-Led Weaning:

Starting solid foods, whether you start with pureed or finger foods, will always be baby-led. If you start with pureed foods, you allow your baby to enjoy the interaction with you until she tells” you she is no longer interested in the feeding by tongue thrusting the food out or by turning away. At this point, end the feeding.

Whether your baby learns to eat pureed foods from a spoon first or learns to chomp or gnaw on solids and turn it into a puree in her mouth likely doesn’t matter much. We don’t think that pureed foods have more or less nutritional value than whole foods. Nor do we feel that pureed foods are inherently more “babyish” than whole foods. Remember, adults enjoy pureed foods in the form of applesauce, hummus, and oatmeal as much as whole foods such as apples, grilled cheese sandwiches, and Cheerios.

Like all developmental milestones, it’s okay to help a child until she is ready to eat on her own. We put clothing on babies before they are able to dress themselves, but eventually they learn to put on their own shirts. In the same way, feeding babies off a spoon helps them until they are capable of grasping food, and later, their own spoons. Even when babies begin to self-feed, they can tire during a meal and need their parents to help.

Some kids do dislike pureed foods and go right to eating solid table food, but you won’t know unless you have tried.

The bottom line: enjoy feeding your child.

Julie Kardos MD and Naline Lai, MD
©2013 Two Peds in a Pod®

For more about starting solids, please see our prior post on this topic.

April is Autism Awareness Month. Here are some signs which may be indicative of autism in your infant. Later this month, we will bring you information about what to look for in toddlers.
Drs. Kardos and Lai

Autism is a communication disorder where children have difficulty relating to other people. Pediatricians watch for  speech delay as a sign of autism. Even before your child is expected to start talking, around a year old, you can watch for communication milestones. Problems
attaining these milestones may indicate autism or other disorders such as hearing loss, vision loss, isolated
language delay, or other developmental delays:

By six weeks of age, your baby should smile IN RESPONSE TO YOUR SMILE. This is not the phantom smile that you see as your baby is falling asleep or that gets attributed to gas. I mean, your baby should see you smile and smile back at your smile. Be aware that babies at this age will also smile at inanimate objects such as ceiling fans, and this is normal for young babies to do.

By 2 months of age, babies not only smile but also coo, meaning they produce vowel sounds such as “oooh” or “aaah” or “OH.” If your baby does not smile at you by their two month well baby check up visit or does not coo, discuss this delay with your child’s health care provider.

By four months of age, your baby should not only smile in response to you but also should be laughing or giggling OUT LOUD. Cooing also sounds more expressive (voice rises and falls or changes in pitch) as if your child is asking a question or exclaiming something.

Six-month-old babies make more noise, adding consonant sounds to say things like “Da” and “ma” or “ba.” They are even more expressive and seek out interactions with their parents. Parents should feel as if they are having “conversations” with their babies at this age: baby makes noise, parents mimic back the sound that their child just made, then baby mimics back the sound, like a back and forth conversation.

All nine-month-olds should know their name. Meaning, parents should be convinced that their baby looks over at them in response to their name being called. Baby-babble at this age, while it may not include actual words yet, should sound very much like the language that they are exposed to primarily, with intonation (varying voice pitch) as well. Babies at this age should also do things to see “what happens.” For example, they drop food off their high chairs and watch it fall, they bang toys together, shake toys, taste them, etc.

Babies at this age look toward their parents in new situations to see if things are ok. When I examine a nine month old in my office, I watch as the baby seeks out his parent as if to say, “Is it okay that this woman I don’t remember is touching me?” They follow as parents walk away from them, and they are delighted to be reunited. Peek-a-boo elicits loud laughter at this age. Be aware that at this age babies do flap their arms when excited or bang their heads with their hands or against the side of the crib when tired or upset; these “autistic-like” behaviors are in fact normal at this age.

By one year of age, children should be pointing at things that interest them. This very important social milestone shows that a child understands an abstract concept (I look beyond my finger to the object farther away) and also that the child is seeking social interaction (“Look at what I see/want, Mom!”). Many children will have at least one word that they use reliably at this age or will be able to answer questions such as “what does the dog say?” (child makes a dog sound). Even if they have no clear words, by their first birthday children should be vocalizing that they want something. Picture a child pointing to his cup that is on the kitchen counter and saying “AAH AAH!” and the parent correctly interpreting that her child wants his cup. Kids at this age also will find something, hold it up to show a parent or even give it to the parent, then take it back. Again, this demonstrates that a child is seeking out social interactions, a desire that autistic children do not demonstrate. It is also normal that at this age children have temper tantrums in response to seemingly small triggers such as being told “no.” Unlike in school-age children, difficulties with “anger management” are normal at age one year.

As an informal screen for autism, children below one year of age should be monitored for signs of delayed or abnormal development of social and communication skills. Home videos of children diagnosed with autism reveal that even before their first birthdays, many autistic children demonstrate abnormal social development that went unrecognized.

Julie Kardos, MD and Naline Lai, MD
©2013 Two Peds in a Pod®
modified from the original  2/3/2010 post

“Mommy, I throwed up.”
Few words are more dreadful for parents to hear, especially at 2:00am (my children’s usual time to start with a stomach bug).

In my house, I am the parent who comforts, changes pajamas and sheets, washes hands and face, and sprays the disinfectant. My husband scrubs (and scrubs, and scrubs) the rug. Little kids never throw up neatly into a toilet or into the garbage can. Sometimes even big kids can’t seem to manage to throw up conveniently.

What should you do when your child vomits?

After you finish cleaning up her and her immediate environment, I suggest that you CHANGE YOUR OWN CLOTHES AND WASH YOUR HANDS! The most common cause of vomiting in kids is a stomach virus, and there are so many strains, we do not develop immunity to all of them. And trust me, stomach viruses are extremely contagious and often spread through entire households in a matter of hours. Rotavirus, a particularly nasty strain of stomach virus, is preventable by vaccine, but only young babies can get the vaccine. The rest of us are left to fend for ourselves.

Stomach viruses usually cause several episodes of vomiting and conclude within 6-8 hours. Concurrently or very soon thereafter, the virus makes an exit out the other end in the form of diarrhea, which can last a week or so.

The biggest problem children face when they vomit is dehydration. Kids need to replace fluids lost from vomiting.  Pedialyte® or other oral rehydration solutions (ORS) such as Kaolectrolyte® or CeraLyte® are useful and well tolerated beverages for rehydrating kids. They contain salt, sugar, electrolytes and water, all substances that kids need when they throw up and have diarrhea.  For babies however, try to “feed through” with breast milk or formula unless otherwise directed by your child’s doctor. Most oral rehydration guidelines are based on diarrheal illnesses such as cholera, so you will find slight variations on how to rehydrate. Basically, they all say to offer small frequent amounts of liquid. I council parents to wait until no throwing up occurs for 45 minutes to an hour and then start offering very small amounts of an ORS (we’re talking spoonfuls rather than ounces) until it seems that the vomiting has subsided. In her house, Dr. Lai uses the two vomit rule: her kids go back to bed after the first vomit  and she hopes it doesn’t occur again. If vomiting  occurs a second time, she starts to rehydrate. Continue to offer more fluids until your child urinates- this is a sign that her body is not dangerously dehydrated.

Can’t immediately get out to the store? The World Health Organization has recommended home based oral rehydration solutions for years in third world countries.  Also, while the oral rehydration solutions are ideal, any fluid is better than none for the first hours of a stomach bug. You can give older kids watered down clear juices, broth or flat ginger-ale with lots of ice.  Now, some kids hate the taste of Pedialyte®. Plain, unflavored Pedialyte® splashed with juice often goes down better than the flavored varieties. For some reason, plain water tends to increase nausea in sick kids and copious amounts of plain water can lower the salt in a child’s bloodstream. So, offer a fluid other than plain water while  your child is vomiting.

Even if your child drinks the Pedialyte®, once the stomach symptoms have subsided, don’t forget that  Pedialyte®, while excellent at “filling the tank,” has no nutrition. The gut needs nutrition to overcome illness. Start to offer small amounts of food at this point. Easy-to-digest foods include complex carbohydrates such as rice, noodles, toast with jelly, dry cereal, crackers, and pretzels.  Additionally, give protein such as bits of turkey or baked chicken. Thicker fluids such as milk and orange juice do not sit as well in upset bellies, nor do large quantities of anything, food or drink. So offer small bits of nutrition fairly frequently and let kids eat as their appetite dictates. Warning- just when everything blows over, toddlers in particular, may go a day without vomiting and vomit one more time as a last hurrah.

Vomiting from stomach viruses typically does not cause severe pain. A child curled up whimpering (or yelling) on the floor with belly pain might have something more serious such as appendicitis, kidney stones, or a urinary tract infection. Call your child’s doctor about your child’s vomiting if you see any of the following:

• Blood in vomit or in stools
• Severe pain accompanying vomiting (belly pain,  headache pain, back pain, etc.)
• No urine in more than 6 hours from the time the vomiting started (dehydration)
• Change in mental state of your child- not responding to you appropriately or  inconsolable
• Vomit is yellow/green
  
• More fluid is going out than going in
• Illness not showing signs of letting up
  
• Lips and mouth are dry or eyes sunken in
  
• Your own gut tells you that something more is wrong with your child

Of course, when in doubt, call your child’s doctor .

Hope this post wasn’t too much to stomach!

Julie Kardos, MD with Naline Lai, MD
©2013 Two Peds in a Pod®

Staphylococcus aureus, is a bacterial strain that has become quite famous – rightly or wrongly depending on the context. In this post, I will share a pediatric infectious diseases specialist’s perspective on the fact and fiction surrounding this germ.

What is MRSA?

MRSA is a particular subtype of Staph aureus bacteria. Staph aureus is everywhere and many people are “colonized” with Staph aureus. In other words, the bacteria live happily on our skin with all the other bacteria, minding their own business. Sometimes, if a person is colonized with Staph aureus, and there is a break in the skin from a cut or other injury, the Staph aureus can cause an infection. This can happen even if a person is not colonized with Staph aureus, because the bacteria are everywhere – in the environment on surfaces, on other people, etc. On people, Staph aureus like to live in the nose and other warm moist places like the armpits and groin area. MRSA is just like regular Staph aureus in where it lives and how it spreads – the major difference between the two is that the antibiotic choices for treating an infection caused by MRSA are more limited because MRSA is resistant to more antibiotics.

Isn’t MRSA rare?

No. In the Philadelphia area where I trained, at least half of skin infections tested are caused by MRSA. In other words, a child having a MRSA skin infection is not a unique event for a community. MRSA is more prevalent than most people realize. In addition to colonization, which you would never know from just looking at someone, many people have minor skin infections for which they never see their doctors because the infection comes and goes on its own with no treatment, or maybe with a little antibiotic ointment. Because samples from these infections are not tested for bacteria, we will never know what caused them and many could be caused by MRSA.

Rarely, a child can have a severe illness as a result of MRSA. This does happen, and appears to be happening more frequently now compared with 10 or 20 years ago, but far more common are simple skin infections caused by MRSA, and the vast majority of these do not progress to serious illnesses.

My grandmother was in a nursing home and died of MRSA. Now my child’s friend had a skin infection caused by MRSA – is this the same thing?

No. MRSA infections that people acquire in hospitals are different from community-associated (CA-MRSA) in a few ways. First, people in hospitals are there because they are ill, often with conditions that make it difficult to fight infections, like being elderly or getting cancer treatment. Second, people in hospitals often have devices that allow entry of bacteria into their bodies more easily, like IV lines or breathing tubes. Third, the strains of MRSA found in hospitals often have different characteristics from those found in the community. In hospitals, MRSA tend to be resistant to more antibiotics and have different properties that make the bacteria more harmful. Also, MRSA infections people get in hospitals are usually not the simple skin infections that children in the community get. Most children who get MRSA skin infections, even recurrent ones, don’t seem to go on to develop other more invasive infections caused by MRSA.

My child was diagnosed with a MRSA skin infection. Will it happen again?

Maybe. If you’ve been told your child has MRSA, don’t panic! In many cases, a single infection caused by MRSA is a one-time occurrence. Some children have recurrent infections with MRSA, but this is far more likely to be an annoyance and inconvenience rather than a serious illness. Recurrent MRSA infections can occur for a period of time, and then not happen again. Some of the time, changes in hygiene practices can stop the cycle of recurrent infection. If your child has recurrent infections, ask your doctor for more information about strategies to try. One important thing to keep in mind is that having MRSA, and even having recurrent MRSA infections, does not mean something is wrong with your child or her immune system – it is just bad luck.

Does someone have MRSA forever?

Maybe, but probably not. As I mentioned above, a significant proportion of the population is colonized with MRSA. The bacteria that colonize our bodies change over time due to a variety of factors, like age, antibiotic use, and environmental exposures. A person could be colonized with MRSA for a period of time, and then never again or not again for years.

Should the school be closed and decontaminated if there is a child with a MRSA infection?

No. Schools should be cleaned as they normally are to reduce bacteria and viruses on surfaces. MRSA and other Staph aureus predominantly live on people, in the nose and other moist body areas, so unless people are decontaminated (not advised!) MRSA can’t be eliminated.

Should kids with MRSA be excluded from school?

Absolutely not. For every one child with a diagnosed MRSA infection there are many more who are colonized with the bacteria, so it does not make sense to exclude a child on the basis of a diagnosis. A child with a MRSA skin infection is not a danger to other children or adults. As with any skin infection, open wounds should be covered. MRSA, while it can in some cases be more harmful than regular Staph aureus, is not any more contagious than regular Staph aureus. A much better strategy than exclusion is to teach children to wash their hands well and to avoid nose-picking, as these interventions will protect them against hundreds of diseases.

Can my child play with his friend who has MRSA?

Yes! As discussed above, a MRSA diagnosis does not say anything about a person’s overall health or make them more likely to transmit disease. Also, your child could very well be colonized with MRSA too and you wouldn’t know it. The best way to prevent the spread of MRSA is to encourage routine hand washing and to discourage nose-picking. Also, avoid sharing towels and sharing sports equipment that rubs against the skin, such as soccer shin guards and football pads. Remember, your child is much more likely to catch a cold or stomach virus from a friend than they are to catch a MRSA infection.

Amanda Paschke, MD, MSCE

©2013 Two Peds in a Pod®

Parents ask us about fever more than any other topic, so here is what every parent needs to know:

Fever is a sign of illness. Your body makes a fever in effort to heat up and kill germs without harming your body.

Here is what fever is NOT:

· Fever is NOT an illness or disease.
· Fever does NOT cause brain damage.
· Fever does NOT cause your blood to boil.
· Unlike in the movies and popular media, fever is NOT a cause for hysteria or ice baths.
· Fever is NOT a sign of teething.

Here is what fever IS:

· In many medical books, fever is a body temperature equal to or higher than 100.4 degrees Farenheit.
· Many pediatricians, consider 101 degrees Farenheit or higher as the definition of fever once your child is over 2 months of age.
· Fever is a great defense against disease, and thus is a SIGN, or symptom, of an illness.

To understand fever, you need to understand how the immune system works.

Your body encounters a germ, usually in the form of a virus or bacteria, that it perceives to be harmful. Your brain sends a message to your body to HEAT UP, that is, make a fever, to kill the germs. Your body will never let the fever get high enough to harm itself or to cause brain damage. Only if your child is experiencing Heat Stroke (locked in a hot car in July, for example), or if your child already a specific kind of brain damage or nervous system damage (rare) can your child get hot enough to cause death.

When your body has succeeded in fighting the germ, the fever will go away. A fever reducing agent such as acetaminophen (e.g. Tylenol) or ibuprofen (e.g. Motrin) will decrease temperature temporarily but fever WILL COME BACK if your body still needs to kill off more germs.

Symptoms of fever include: feeling very cold, feeling very hot, suffering from muscle aches, headaches, and/or shaking/shivering. Fever often suppresses appetite, but thirst should remain intact: drinking is very important with a fever.

Fever may be a sign of any illness. Your child may develop fever with cold viruses, the flu, stomach viruses, pneumonia, sinusitis, meningitis, appendicitis, measles, and countless other illnesses. The trick is knowing how to tell if your child is VERY ill or just having a simple illness with fever.

Here is how to tell if your child is VERY ill with fever vs not very ill:

Any temperature in your infant younger than 8 weeks old that is 100.4 (rectal temp) degrees or higher is a fever that needs immediate attention by a health care provider, even if your infant appears relatively well. For kids over 2 months of age, take the temperature anyway you’d like, just let your pediatricians know how you took it.

Any fever that is accompanied by moderate or severe pain, change in mental state (thinking), dehydration (not drinking enough, not urinating because of not drinking enough), increased work of breathing/shortness of breath, or new rash is a fever that NEEDS TO BE EVALUATED by your child’s doctor. In addition, a fever that lasts more than three to five days in a row, even if your child appears well, should prompt you to call your child’s health care provider. Recurring fevers should also be evaluated.

Should you treat fever? As we explained, fever is an important part of fighting germs. Therefore, we do NOT advocate treating fever UNLESS the side effects of the fever are causing harm. Reduce fever if it prevents your child from drinking or sleeping, or if body aches or headaches from fever are causing discomfort. If your child is drinking well, resting comfortably or playing, or sleeping soundly, then he is handling his fever just fine and does not need a fever reducing agent just for the sake of lowering the fever.

A note about febrile seizures (seizures with fever): Some unlucky children are prone to seizures with sudden temperature fluctuations. These are called febrile seizures. This tendency often runs in families and usually occurs between the ages of 6 months to 6 years. Febrile seizures last fewer than two minutes. They usually occur with the first temperature spike of an illness (before parents even realize a fever is present) and while scary to witness, do not cause brain damage. No study has shown that giving preventative fever reducer medicine decreases the risk of having a febrile seizure. As with any first time seizure, your child should be examined by a health care provider, even if you think your child had a simple febrile seizure.

Please see our “How sick is sick?” blog post for further information about how to tell when to call your child’s health care provider for illness.

Julie Kardos, MD and Naline Lai, MD

rev © 2015 Two Peds in a Pod®

Happy 2013! Time start those new year resolutions. If you are like many families, your kids are up early anyway so you might as well get started (or maybe they never went to bed). To jump start your list, we’re sharing a list of New Year’s health resolutions we’ve come up for our own families over the years.

1- I will make sure my child is up to date on her vaccines, including the yearly flu vaccine (there’s still time).

2- I will start to sleep train (if older than 6 months old).

3- I resolve to wean the bottle if my baby is older than one year.

4- I will read aloud to my child every day, even after he is old enough to read to himself.

5- I resolve to go through the medicine closet, dispose of out-of-date medications, and renew important rescue-type medicines such as epi-pens and albuterol.

6- I resolve to check to see that my child’s bike helmet still fits (consider putting name and contact telephone number on outside…just in case something were to happen) and tuck emergency phone numbers into her backpack.

7- I will start to read my child’s facebook page and phone texts. I’ll look for signs of bullying and signs of mental distress from my child’s friends as well as from my child. I will take action to address any problems.

8- I will remember to praise my child for acts of kindness and for working hard on school assignments.

9- I’ll get to know my kid’s friends and their families. I will start by getting out of the car to say hello when I drop my kid off at someone’s house.

10- I plan to encourage more self-sufficiency in my child. I’ll stop doing household tasks for my child when he shirks his duties. 

11-I will turn off my cell phone while I am doing an activity with my child.

12- I will listen carefully to my child’s own New Year’s Resolutions.

Have a wonderful, healthy 2013,

Drs. Kardos and Lai

©2013 Two Peds in a Pod®

Even if breastfeeding is going great for you early on, it’s still normal to feel more tired than ever before. Today, pediatrician and breast feeding expert Dr. Esther Chung gives motivating advice on nursing:

Breastfeeding has many health benefits for babies, mothers and society.  Babies who are breastfed have lower rates of ear infections and diarrheal illnesses. They are at lower risk for asthma, obesity and even leukemia.  Mothers who breastfeed are also at lower risk for breast and ovarian cancer and they have less postpartum bleeding. 

Remember in our post about the early weeks of breastfeeding where we encouraged you to stick with it because it gets easier? Dr. Chung concurs:

For some women, breastfeeding comes easily.  They experience little discomfort, their babies latch on easily, and they produce a lot of milk.  For most, breastfeeding is challenging in the first 1-2 weeks following birth, but by the time the baby is 4-5 weeks old, breastfeeding is easy.  Having patience and trusting that your body will produce enough milk are the keys to breastfeeding success.  Maternity hospitals that employ trained professionals with International Board Certified Lactation Consultant (IBCLC) credentials have higher rates of breastfeeding.  After leaving the hospital, families can find IBCLCs in their neighborhood by entering their zip code into the International Lactation Consultant Association website, http://www.ilca.org/i4a/pages/index.cfm?pageid=3432. 

Dr Chung’s Tips to Successful Breastfeeding

• Hold your baby skin-to-skin on your chest. This means your baby’s body is in direct contact with your skin.  You may choose to wear a gown that opens in the front and your baby should wear a hat and diaper to minimize heat loss.  Skin-to-skin contact allows your baby to maintain a normal temperature and prepares him/her to feed.  As a result, most babies will search for the breast and breastfeed.
• Initiate breastfeeding within the first hour of life. 
• Request that your baby stay in your room (“rooming in”) so you can breastfeed when your baby is ready.
• Request that your baby only breastfeed – no bottles, no formula.
• Expect to breastfeed throughout the night.  Rest while your baby is resting.
• Take your baby to see his/her health care provider 2 to 3 days after leaving the hospital/birthing center.
• Find out how your workplace supports breastfeeding mothers – for example, do they provide a lactation room or other facility for mothers to pump milk during breaks?
• Discuss with your baby’s health care provider and/or your breastfeeding support group the many ways to maintain your milk supply after returning to work.
• Learn more about breast pumps, which you can rent or buy.  Some health insurance will cover related costs.

Returning to school and work may pose challenges for some women.  In 24 states, there are laws related to breastfeeding and the workplace (see http://www.ncsl.org/issues-research/health/breastfeeding-state-laws.aspx). Section 4207 of the Affordable Care Act is a federal law that requires all employers to provide time and space for women to pump milk, but employers with less than 50 employees can apply for exemption if there is undue hardship (see http://webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId=24540).

Esther K. Chung, MD, MPH, FAAP

Currently a Professor of Pediatrics at Jefferson Medical College and Nemours, Dr. Chung won the 2009 Physician of the Year Award from the Pennsylvania Resource Organization for Lactation Consultants (PRO-LC) and the 2008 Special Achievement Award from the Pennsylvania Chapter of the American Academy of Pediatrics (AAP), for breastfeeding advocacy work. A member of several breastfeeding advocacy groups including the International Lactation Consultants Association, she frequently lectures nationally to healthcare professionals on breastfeeding topics.

For Two Peds in a Pod’s suggestions for how to continue breastfeeding when returning to work,  see our earlier post on this subject. Drs. Kardos and Lai

©2012 Two Peds in a Pod®