Archive for the ‘Medical problems’ category

Heart murmurs in children are usually nothing to worry about

January 17, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Here’s a question: “My daughter was found to have a heart murmur at a well check. Is this something I need to worry about?”

A murmur just means a noise—the noise of blood swishing through the heart and blood vessels of the chest. Because children have thin chest walls and very little fat under their skin, murmurs are heard very commonly in kids. About 50% of kids will have a murmur heard at least once during their childhood.

Almost all of these murmurs heard in healthy children mean nothing. Their hearts are fine. In adults, though, murmurs often mean there is some kind of problem with the heart. This is a good example of how different kids are from adults.

Evaluating a newly-heard murmur starts with asking about the history. Is there anything going on that possibly suggests a heart problem? For instance, has there been fainting or chest pain during exercise? Is there a family history of heart problems in young people? Murmurs are always more concerning in a child whose history is suspicious for possible heart disease.

The murmur itself needs to be listened to carefully, often while moving the child into different positions. Based on how it sounds, a pediatrician can tell how likely that particular noise is to indicate an actual heart problem. Since most murmurs in kids are normal, we don’t usually refer all of them to cardiologists or for testing (if we did, there wouldn’t be nearly enough cardiologists or EKG machines.) If I listen to a murmur and I’m confident it’s normal, I’ll tell that to the parents and I won’t refer. If I listen to a murmur and I think it might be an abnormal sound, or if I’m worried based on the history or other findings, I’ll refer the child for further evaluation.

Murmurs (especially normal murmurs that don’t mean anything) come and go. Doctors can hear them better when the heart beats stronger (for example, during a fever or when a child is excited). Murmurs may be missed if a child is upset or yelling during an exam. Though some are present from birth, it’s not unusual for a murmur to be first heard in a child at any age.

So: though most murmurs in children are normal, they do need to be evaluated carefully by considering the history and complete physical exam. Many can be easily distinguished at the pediatrician’s office as normal, without further testing. Others are kind of borderline, and may turn out to be normal—but need additional confirmation to prove that. If as a parent you’re uncomfortable without confirmation that a murmur is normal, speak up—don’t just worry silently. I never mind doing a referral for reassurance for myself, OR a parent.

Can a face mask prevent flu?

January 14, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

We’re still swamped with flu at the office—this year is bad, bad, bad. I’ve recently written about preventing and treating influenza, and another detailed piece about exactly how flu is transmitted and how to protect yourself.

What about face masks? You see them on TV this time of year, and maybe you’ve seen them at your doctor’s office. Should flu patients wear masks? Should all of us?

There’s some evidence supporting the use of masks to prevent transmission of flu to healthy people. Studies have looked at both household and dormitory transmission of flu, and healthy people who routinely wear masks are less likely to contract flu, even when people sharing living quarters have influenza. The effect is largest when mask-wearing is combined with hand washing, vaccinations, and other steps to limit contagion.

As far as putting a mask on people who themselves have the flu: I could find no studies showing that this actually works. It does make sense to keep flu victims out of the workplace and away from other people, and perhaps putting a mask on them will also help. But it’s not clear that this will really make a difference.

Why would wearing a mask help prevent a healthy person from catching flu? A cough from a flu patient within three feet of your nose or eyes can transmit flu, so perhaps a mask could block that (there is no evidence that this is actually true.) More importantly, wearing a mask will remind you NOT to touch your nose or mouth. So even if you do get contaminated, infectious mucus on your hands, it won’t get you sick.

I’ve covered the best ways to prevent flu before: avoid sick people, wash your hands, don’t touch your face, and get immunized. Perhaps wearing a face mask can also help (I don’t recall these guys getting the flu!) Hopefully, this year’s flu season will burn out soon, and most of us will make it through OK. Next year, be sure to get that vaccine, OK?

How to transmit influenza to your friends and enemies

January 11, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Influenza has hit, and hit hard. This year is shaping up to be one of the worst years in memory. Flu is now widespread in almost every state, and we may not yet have hit the peak.

You know it’s gotten bad when CNN routinely shows video of people walking around in surgical masks. Is it likely that wearing a mask will really help?

Flu is a specific virus—it’s not just a bad cold. Every winter there’s a surge in cases, though some winters are worse than others. The virus is transmitted in blobs of mucus expelled by people. If you’ve got the flu, you started spreading the germ one day before you got sick, and you’ll probably keep shedding virus around for about 5 days after the fever starts.

The mucus that contains the flu virus can fly out of your nose or mouth, and can infect anyone who gets that mucus in their eyes, nose, or mouth. The coughed particles don’t travel far. To transmit flu via the air, your victim has to be standing within about three feet. Anyone further than three feet away probably won’t catch flu, even if they’re coughed or sneezed on.

So airborne spread is possible, but only within about three feet. More commonly, flu is spread through the contamination of surfaces. Here’s how it works:

1.     Johnny’s got the flu.
2.     He sneezes on his hands.
3.     Johnny touches a doorknob.
4.     His sister Sarah touches the same doorknob.
5.     Sarah rubs her eye with the same hand that has Johnny’s flu germs from the doorknob.
6.     Boom. Sarah’s got the flu.

There’s a lot of steps that have to take place, and at every step there are things to do to prevent transmission:

1. Johnny’s got the flu. Preventing Johnny from getting the flu is an important step in preventing transmission! The fewer flu victims, the fewer flu transmission to the rest of us. Prevent the spread of the flu doesn’t just help your own family—it helps all of us!
2.   He sneezes on his hands. “Mucus hygiene” means teaching your children (and yourself) NOT to sneeze and cough into your own hands. If your hands have infectious germs on them, you’re close to spreading them around. Instead, cough into the crook of your elbow. Washing and sanitizing hands is also crucial for preventing transmission.

3.     Johnny touches a doorknob. It may not be practical not to touch anything when you have to flu—but keeping flu victims out of the public, and in their own bedrooms, will at least keep most of their germs where other people won’t touch them.

4.     His sister Sarah touches the same doorknob. Sarah’s not sick—yet. She ought to not be hanging around Johnny’s stuff. Stay away from people with flu!

5.     Sarah rubs her eye with the same hand that has Johnny’s flu germs from the doorknob. This step is very important. Flu virus on your hands does not make you sick. You can still spread it around, but you won’t yourself get sick until the virus touches a part of your body it can invade: your eyes, your mouth, or your nose. If you can develop a lifelong habit of NOT rubbing your eyes, NOT picking ot rubbing your nose, and NOT sticking your fingers in your mouth you will NOT get sick as often. Try it. If you do have to rub your eyes, wash your hands first, or rub your eyes with a tissue.

6.     Boom. Sarah’s got the flu. There’s one more line of defense—vaccinations! Though imperfect, flu vaccines protect you from flu, even if the virus gets into your system.

  

This year’s flu vaccine so far is proving very effective. About 90% of people who’ve been vaccinated 2 or more weeks prior to contact are completely immune, and won’t get sick at all. The remaining 10% are only partially protected—they may still get flu, but it will be at least milder.

And keep in mind: everyone who doesn’t get the flu – because they’re vaccinated and/or because they’re following the advice in #1-6—is one less person spreading flu. Fewer get it, fewer spread it.

We’re all in this together, folks. Flu can be treated, but it’s even better to prevent it in the first place.

Earlier: Preventing and treating influenza

Who needs a pediatric dentist? And when?

January 9, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Tanya asked, “Should I take my kids to a pediatric dentist?”

Maybe, maybe not. Children do need a dentist who’s sensitive and good with children—but that doesn’t necessarily mean it has to be a pediatric-only dentist (or “pediadontist”.) Many family dentists do a great job with everyone. I think it’s fine if parents take their kids to their own dentists, as long as the dentist is comfortable and good with children.

How can you tell? Ask. I think most dentists who prefer not to see children will tell you that, right up front. If your dentist says, “Well, we rarely see kids here” that tells you something. You should also look around the office and waiting room. If there are no kid-friendly toys or murals about, chances are children rarely go there. Do all the magazines feature Oprah, or are there little short chairs next to a sand table? Subtle clues abound.

There are some dental procedures that require specific child techniques or anesthesia, best done in a child-only practice. Your own dentist will refer you to a ped-dentist if that’s what you need. If you’re ever uncomfortable about anesthesia in an adult office, ask your dentist how often they do that. Or get a second opinion from a pediadontist.

According to the American Dental Association (ADA), children should have a dental home by age one. I’m not sure that’s always necessary or practical. The ped dentists near me recommend seeing children for a first visit at age 3 – 3 ½.

Whenever you decide to see a dentist, follow these tips to keep teeth clean and healthy starting young:

  • Never put a baby to bed or nap with a bottle.
  • Start brushing at age 1 with a soft brush and a tiny, rice-sized dab of fluoride-containing toothpaste.
  • Stop using baby bottles by 12 months of age—especially the one that leaves baby’s mouth full of milk at bedtime. After a last snack, brush teeth before bed.
  • Once complementary foods are added, babies should also drink water with meals. Water—not juice, not anything sweetened. Water. Ordinary, cheap, fluoridated tap water. Mmmmm.
  • Avoid sugary drinks, including juice, which is about as nutritious as soda.
  • Don’t let your child stroll around all day with a sippy cup.

If you haven’t been able to follow those steps, or have a strong family history of teeth problems, or you or your child’s doctor see problems with your child’s teeth, you ought to head to the dentist early—by age 1, as the ADA recommends. Whether it’s a ped-only or a general, family dentist is probably less important than overall good nutrition and dental habits.

One easy way to tell if a rash is serious

December 21, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Rashes are tough to diagnose over the phone. Even if you MMS me a pic, I can’t really feel it or get an overall gestalt of what the child and the rash looks like. (And, of course, MMS isn’t HIPAA compliant. Heaven forbid the gummit allow us to do something that might be easy, cheap, and helpful.)

Most rashes can easily wait a day or two for diagnosis. In kids they’re often triggered by mild viral infections, and the rash will go away on their own without therapy. Itchy things like eczema or poison ivy or contact derm get better with over-the-counter hydrocortisone.

On the other hand: some rashes, especially if accompanied by fever, can be a warning sign of a potentially catastrophic condition. Meningitis, sepsis, and leukemia can all present with a rash.

Yikes!

So, here’s one good, middle-of-the-night way of helping parents decide if a rash needs immediate attention:

As always, the posts and comments on this blog are general info to educate and inform. I am not your doctor, and this is not specific medical advice for your individual situation. If you’re worried, contact your own doctor directly. Also, the following info is only for healthy, ordinary kids who have been fully vaccinated. If your child has chronic health issues, immune problems, or is under-vaccinated, he is at much higher risk of serious complications.

Step 1. Does the child seem OK? If your child has a rash (or even if he doesn’t have a rash), your first question is: does he seem very sick? If Junior is hard to wake up or very pale or grey-looking or having trouble breathing or just doesn’t seem right, get thee to the nearest ER, pronto. Don’t mess around with the internet, and don’t mess around with trying to figure out what a rash means. Very sick-seeming child = trip to ER. Go.

Step 2. If your child with a rash seems reasonably well, but maybe blah with a fever, treat the fever first. The fever itself is not harmful, but it will make your child feel bad. Once the temperature starts to come down, you’ll be able to re-assess just how sick your child is. A vaccinated, healthy child who’s comfortable and playing after fever reduction is very unlikely to have anything seriously wrong with him, and almost certainly doesn’t have to go to the ER or see a doctor immediately.

Step 3. Assuming your child seems reasonably well, let’s see if this really is a rash that needs immediate evaluation:

Take a thick glass or a tumbler, and press the side of the glass against the rash. Peer through the glass at the skin. If the rash disappears with the pressure of the glass, it’s unlikely to be anything serious. If the rash can still be seen through the glass, it could well be a serious rash called “petechiae” or “purpura”, which is bleeding under the skin. Though petechaie are not always a serious problem, it can be. Contact your doctor or go to the ER if your child has these kinds of rashes that don’t disappear with the pressure of a glass.

One caveat: vomiting or coughing or straining hard can cause a little bit of petechiae on the upper face or around the eyes. Don’t worry too much about that. But widespread petechiae do need attention.

That’s all it is: the “tumbler test”, a quick and easy and cheap way to diagnose the most-concerning rashes of childhood. We’d better keep this quiet, or some drug company will start selling a sterile one-use shot glass for $600. It’ll be FDA-approved, as long as you don’t take a picture of it to text to your doctor.

Preventing and treating influenza

December 18, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

We’re now at what’s probably the height of influenza season. My office saw about 30 cases this week—that’s plenty of fever and misery. What’s the best way to cope?

First: an ounce of prevention. Please, if you or your children are ill, stay home. Do not go to school. Do not go to the mall. Do not go sit in Santa’s lap and cough in his beard. We need to do the right thing as individuals to help keep our communities safe.

And wash your hands, people!

Vaccines are a good idea for everyone aged 6 months and over. Don’t believe the nay-sayers. I know the fad is to look down on vaccines, belittle them, and be the cool family who doesn’t get their shots. Influenza is not cool, and you will not be happy when your kids get sick. By then it’s too late. (It’s not too late now—but it’s getting close.)

Still, even with good hygiene and vaccines and common sense, the influenza virus is fabulously contagious. Even in the best years, about 10% of vaccinated individuals are still susceptible. What do you do when you or your kids get the flu?

It’s all about comfort. Drink plenty of fluids: water, juice, Gatorade, popsicles, whatever. If it’s wet, it’s good. Yes, milk is OK—even the highest fevers of influenza aren’t nearly high enough to curdle milk.

Get rest. Stay in bed. Don’t go to work or school.

Though the fever of influenza makes you feel bad, it won’t hurt you. Still, misery is miserable, so try to treat fevers with the correct, safe doses of either acetaminophen or ibuprofen. Watch the labels, and use them correctly. It’s best to write down what you gave, and when you gave it, so no one gets confused in the middle of the night.

One strategy to help keep fevers down is to “alternate” ibuprofen and acetaminophen, giving one and then the other alternating every three hours, so neither one is given more often than every six hours. A few studies have shown that this is perhaps a little more effective than relying on one medication. But it can be confusing, and there’s concern that this regimen makes it more likely that a dangerous mistake will occur. If you do alternate, make sure you’re using careful measurements of the correct dose, and definitely write down what you’ve giving and when. Remember, though fever doesn’t feel good, it cannot hurt you. Don’t do anything unsafe because of fever fears.

Although a tepid bath can reduce fevers, never use a cold bath, and absolutely never rub down a child with alcohol to reduce fevers.

Influenza is often accompanied by some congestion and cough. Honey can be an effective cough reliever, and a steamy shower or humidified air can also help. Prescription and non-prescription cold and cough medicines just don’t work very well, and are unsafe in young children.

What about the prescription medication, Tamiflu? This is drug that specifically suppresses the spread of flu virus in your body. It can help shorten the duration and severity of flu—but really, only modestly, and only if it’s started within the first 24 hours of fever. After that, it’s pretty much useless. Tamiflu often causes nausea, so sometimes people can’t take it. If your doctor has prescribed Tamiflu, you can take it in addition to the symptomatic therapies and medicines listed above.

An ordinary case of flu includes fever, aches and misery for about 4-5 days (the disease is milder and shorter if you’ve been vaccinated, even if you’re unlucky enough to catch it anyway.) The treatment is mostly fluids, rest, and fever reducing medicine. Have some soup. Stay home, and don’t spread it around. Come to think of it: just do what your Grandma would have done, and you’re probably doing the best you can.

And make sure Grandma gets her vaccine, too!

School morning belly aches: Are they “real”?

December 14, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Dave’s story: “I have a six year old who gets a lot of belly aches. She’s seen her ped and a GI, and all the tests say nothing. Her belly aches really only happen in the morning before school. I think it might be psychological, and have told her about the boy who cries wolf, but she insists that her tummy hurts. What should we do?”

We need to settle one thing up front. These belly aches are in every sense “real”, even if they’re related to psychological factors on school days. The pain is real, because the pain hurts. Telling her that it doesn’t hurt, or talking with her about boys and wolves, is unlikely to help her feel better.

There’s this weird, false dichotomy in medicine between “real” and “not real” in the way we talk about medical problems—as if psychiatric or psychological issues are less important in some way. Sometimes words like “organic” are used for “real” pathology, as opposed to “inorganic”, whatever that means. You’ll also see references to “functional” pain, somehow implying that this kind of pain is somehow less real. But it still hurts!

There’s even a specific name for “GI pain where no pathology can be seen through a microscope and no lab tests are abnormal but nonetheless it hurts and ow I wish it would feel better.” It’s called irritable bowel syndrome, and it affects millions. Again: it hurts.

Dave’s already taken an important step: by keeping track of the symptoms, he’s narrowed this down to a school-morning phenomenon. That’s very important information, because it tells us that we don’t need more invasive tests or procedures. Instead, we ought to be focusing on ways to help the child feel better. Is there a specific stressor (like a bully) at school? Can we reduce overall stress in other ways? Can we think of ways to make school mornings a little less dread-inducing? Perhaps, in addition to reducing stress, we can also start to teach the child new ways of dealing with stress—like a special lovey to hug, or a punching bag to whale on (you can see, the approach may depend on the child!) Things like a hot water bottle, extra time on the toilet, or waking up early enough so the family doesn’t have to rush can all help.

The bottom line: belly aches that only happen on school day mornings are real. Parents won’t be able to talk their child out of it. Instead, we ought to be working with our children to see how we can help them feel better.

Vitamin B12 quackery

December 6, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Here at The Pediatric Insider, we’re about science. Medicines and other treatments need to be tested. We want reliable proof that something works and is safe before we recommend it. We don’t like the false dichotomy of “alternative medicine”. If there is good evidence that it works, it’s medicine. If it doesn’t work, it’s quackery.

It doesn’t matter who’s doing the quacking. A quack is a quack, even if there’s a medical diploma on the wall.

The story: a woman brings in her teenage daughter, complaining that the girl is tired a lot. It turns out that mom herself has had some blood tests that showed a low vitamin B12 level, so her doctor is giving her regular B12 injections. Can her daughter get some, too?

I realize that B12 injections are common. Many docs administer these, and many adults get these—probably some of you reading this. So what’s the science behind this practice?

Vitamin B12 deficiency is a real thing. It can occur because of a poor diet, or because some medications (like acid blockers) interfere with absorption. Or it can occur because of a specific autoimmune disorder called “Pernicious Anemia.” Whatever the cause, the health consequences of vitamin B12 deficiency can include anemia, neuropathy, irritability, and depression.

There is a simple blood test to measure vitamin B12 levels, though the levels in the blood don’t always correlate with whether there is enough B12 levels in the cells themselves. We can test for this, too, indirectly, through other blood tests including methylmalonic acid and homocysteine levels. So we can, in fact, know if a person is truly deficient. These confirmatory tests are rarely done.

Instead, many adults are told that their vague symptoms of tiredness or fatigue are caused by B12 deficiency, instead of actually trying to address genuine issues like insufficient sleep, sleep apnea, overreliance on caffeine, and depression (to name a few of the many genuine causes of fatigue.)

It gets worse. The treatment of B12 deficiency, as has been established from studies done in the 1960s, is ORAL B12. That’s right. Pills. Injections of B12 are not necessary—oral supplements work well, even in pernicious anemia. They’re cheap and they work. I suppose a very rare patient, say one who has surgically lost most of their gut, could require injections. But the vast majority of people with genuine B12 deficiency can get all of the B12 they need through eating foods or swallowing supplements. No needles needed.

So why this fetish with injections? From the patient’s point of view, shots feel more like something important is going on. Placebos need rituals—with acupuncture, for instance, the elaborate ritual creates an illusion of effectiveness. And from the doctor’s point of view, injections reinforce dependence on the physician, creating visits and cash flow.

So: people seem to think they feel better with injections, and the doctor makes a little cash, and everyone’s happy. So what’s the harm in that?

I think it’s wrong to knowingly dispense placebos, even harmless ones. We doctors like to criticize the chiropractors and homeopaths. We point fingers. They’re the quacks. We’d better take a close look at what we’re doing, first. Our placebos are sometimes far more dangerous than theirs.

More importantly, people should be able to expect more from physicians. Patients come to us for genuine answers—if they wanted a witch doctor, they would have found one. I think we need to hold ourselves to a higher standard than a huckster at the carnival. We’re not here to promise that we’ve got all the answers. We are here to be honest, and to use the best knowledge that science has to offer, using  genuine compassion and thought. Let’s leave the quacking to the quacks. We’ll stick with real medicine.

Breast Cancer versus HIV screening: Always a good idea?

November 30, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Screening tests to looking for disease early may not always be a good thing.

On one side: The Unites States Preventative Services Task Force– or USPSTF– now recommends universal screening for HIV infection among all adults aged 15-65. Their draft statement, released this week, now agrees with the CDC’s 2008 recommendation, which essentially said the same thing in 2006.

Contrast this with a study of screening mammography published in the New England Journal of Medicine a few days ago. Looking at over 30 years of data, researchers found  that up to a third of tumors identified by screening mammography were likely diagnosed incorrectly. They were in fact harmless. That’s a lot of women undergoing biopsies, surgery, radiation, and chemotherapy. The authors say that their study supports the 2009 USPSTF recommendation that most women in their 40’s not undergo routine mammograms.

So why the difference?

Whether to screen or not depends on the answers to some tricky questions:

How accurate is the screen? In the case of HIV testing, it’s very accurate. Mammography? Many false positives, and some false negatives too.

What happens after a positive screen? HIV screening tests lead to a few more blood tests to confirm the diagnosis. A positive mammo leads to biopsies and surgery and maybe more.

What happens if we miss a diagnosis? HIV positive individuals spread infection. Earlier diagnosis of HIV can not only lead to effective treatment, but also to an overall reduced risk to the population. Breast cancer isn’t contagious, and it’s unclear that earlier treatment is always better—some small tumors may regress without any treatment at all.

We have a lot more to learn about the answers to these questions, and recommendations for screening should always be based on the best available science. What strategy keeps the most people healthy, does the least harm, and is the most effective way to spend health care dollars? These answers aren’t always obvious, and new studies sometimes lead to new perspectives.  But it is clear that not every screening test is a good idea for everyone.

Baby sleep positioners kill

November 26, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

The AAP has been warning against these things for years, and finally the FDA and CPSC have weighed in: Infant sleep positioners don’t prevent SIDS, and don’t save lives. But they can kill your baby.

These things are wedge-shaped or U-shaped gizmos that are supposed to keep your baby in a certain position while sleeping, supposedly to prevent SIDS and other alleged problems. But the “back to sleep” anti-SIDS campaign, which has reduced deaths by over 50%, never suggested to have to keep your baby on his back. The message from the back to sleep campaign has always been to put your baby down on his or her back, then to go away. Once your baby can move or roll to a different position, that’s fine.

The SIDS prevention guidelines are pretty straightforward, but that hasn’t stopped companies from capitalizing on fear to sell devices that they claim will reduce SIDS. Special monitors, mattresses, pillows, bumpers, and infant positioners have all claimed to protect babies, yet the FDA (nor the AAP, nor anyone else who knows what they’re talking about) has ever endorsed or approved any such device.

Want to prevent Sudden Infant Death Syndrome? Here are some proven methods. These are from the AAP’s Details and references are all in the AAP’s 2011 policy statement on preventing SIDS and other sleep-related infant deaths, which includes more details and references for all of these recommendations.

  • Breastfeed.
  • Immunize – follow the established schedule, which reduces SIDS by about 50%.
  • ALWAYS put your baby down to sleep on his or her back.
  • Don’t use bumper pads or other padded fluffy things in the crib.
  • Always use a firm, flat sleep surface. Babies should not routinely sleep in carriers, car seats, or bouncy seats.
  • Place your baby on a separate sleeping surface, not your bed (Bed sharing is discouraged.) Babies can sleep in their parents room, but should not sleep in their parent’s bed.
  • Wedges and sleep positioners should never be used.
  • Don’t smoke during or after pregnancy.
  • Offer a pacifier at sleep and naptimes.
  • Avoid covering baby’s head.
  • Avoid overheating.
  • Practice supervised, awake tummy time to help motor development and avoid flattened heads.
  • Ensure that pregnant women and babies receive good regular care.

The AAP’s recommendations not only address specific, known, modifiable risk factors for SIDS, but also help reduce the risk of death from suffocation and other causes. They are the best way to help keep your baby safe. Forget the hype and expense and unfounded promises from manufacturers—you can best keep your baby safe without buying anything.


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