Ear Piercing?

I still offer ear piercing in my office as I always have. However, in truth, the requests are less frequent than in the past, mostly due to my present approach to the issue. Ear piercing is a quick and generally very safe procedure; mostly the pain involved is mild enough to be tolerated by even the most squeamish among us. The AAP position on ear piercing is that it is permissible for cosmetic reasons for all children but is best limited to those who are old enough to administer care for the piercing themselves. I concur, although my logic is more along the lines of ethics/philosophy as opposed to medical reasons. Let’s discuss.

I stick children with needles all the time, of course–mostly immunizations, but also lidocaine injections for suturing/stapling of lacerations among a few other situations. Additionally, of late, I regularly obtain nasal swabs to test for covid. Most of us are now unfortunately quite familiar with the discomfort associated with that test. In the large majority of all of those instances, I do NOT have the child’s cooperation to perform the procedure; we have to hold him/her still a bit against his/her will. However, what I do have is the parents’ permission–based on their accepting my advise that that otherwise unpleasant intervention is in the best interests of their child’s health and well being, and based on that, I disregard the child’s (sometimes screaming!)objections.

But that ethical standard does not apply with ear piercing. Here it’s purely cosmetics and esthetics: WE think the baby looks cute with earrings; the baby certainly doesn’t care. But–babies look really cute whether they wear earrings or not, right? And it’s essential to keep in mind that that adorable, innocent little creature is not some object or possession but rather a sentient human being. They presently may have at best only limited ability to express their wishes. But they retain–or should have–the basic human right to make those decisions regarding bodily integrity for themselves. Even parents should respect that boundary: every person has the right to say “don’t do this to me without my permission.” Only with the above exception of health essentials not comprehensible at the child’s level of development should anyone override that person’s right in that regard.

One of my roles as the pediatrician, I believe, is as an advocate for my patient. So my present approach is to pierce ears ONLY for children who themselves specifically ask for it. And I take that advocacy seriously, so I also reserve the right to judge if a younger patient is sincere in the request and not merely innocently responding to the genuine if a bit too encouraging efforts on the part of the parents. If the child wants it–sure! But only for children who legitimately want it; everybody else can wait until then. My office, my rules, right?

If you have questions regarding ear piercing for your child, please give our office a call. Thanks for following.

Update on HPV Vaccination

Let’s take a moment to review the importance of getting your teens vaccinated. But I’m not discussing “that” vaccine: I’m talking about gardasil, the HPV (“human papilloma virus”) vaccine. HPV spreads via all variations of intimate contact (let’s leave it there!), and is responsible for up to 90% of all cancers of anogenital tissues of both sexes. Unvaccinated, virtually all sexually active people will be infected with HPV by their late 20’s.

HPV now has been approved and in use for a long time: 2006 for US females, ’07 in Australian girls; in 2014 for US males and 2013 for Australian males. It’s safety record is definitive and strong. As with all vaccines, one can find anecdotal claims of vaccine associated serious reactions. However, none of these have ever stood up to scientific analysis. If, after vaccination, (this) happens, that doesn’t establish that vaccination caused (this), even if nobody can find any other cause of (this)in the affected person. In fact, in these instances, all careful investigation has found that (this)–whatever (this) was–happens at the same rate in the unimmunized as the immunized population. In other words, the vaccination followed by(this) was simply a terrible, sad coincidence and nothing more. A 2013-16 study of >1000 women aged 20-33 showed that HPV vaccinated women were LESS likely to complain of infertility compared to unimmunized women. Research by the Kaiser Family Foundation showed that immunized women were no more likely to be treated for STD’s or to conceive out of wedlock compared to those unimmunized, demonstrating similar approaches to their sexuality by both groups–immunized girls did not engage in more or riskier sex practices.

With this long history of safe use we also see the positive effects of immunization. Australia introduced a program of free vaccination for all eligible citizens with licensure; cervical cancer rates are down 90% since, and their doctors postulate that that disease can be eliminated from the human population by 2050 with universal vaccination. US vaccine coverage has lagged Australia’s, but we have been “catching up” of late, and recent data demonstrates a decrease of HPV infection in women <25 by 80%. This is excellent news, and, given Australia’s experience, strongly suggests that we can expect decreasing rates of cervical cancer in these women in the coming years.

HPV vaccination is more effective with earlier administration. Teens<15 require only 2 shots for protection, while 15+ need 3 over at least 6 months. Given the above safety record, I say curing cancer is a very good thing. Gardasil is indicated 9+ years; most pediatricians begin at age 11. Waiting until later teens is unnecessary and illogical. These 2 events–being immunized and being sexually active–have nothing to do with each other. The idea is to have your child protected BEFORE the issue of sexuality enters their lives. And, I admonish parents (as gently as possible), that they only have so much control over that aspect of their growing young adult’s life; with each passing day that control diminishes.

So do what you can to extend your control and protect your child from this cancer causing infection:schedule your teens for their HPV vaccine. Thanks for following.

“Pandemic Eye”

As the covid pandemic has gripped our society across the globe, pediatricians and parents have all noted new and often serious associated health risks for children. Previously I discussed concerns regarding increased screen use among children and adolescents, as well as avoidance strategies for that practice. Another upsetting trend is an alarming increase in eye injuries from alcohol based hand sanitizers(ABHS).

A French based study noted a 7 fold increase in their poison control contacts regarding these eye injuries. Most involved children <4 years; many cases occurred when families were out in public places like shopping malls as opposed to in the home. While most cases were mild and no instances or permanent eye damage were reported, there was an upsetting number of cases deemed “moderate” in severity–involving “keratitis” with corneal abrasions and burns. Those incidents could still result in more persistent eye problems–only time will tell. Of note is that, by definition ABHS is sanitary, so infections as a result of these injuries is not a problem.

The reason for this new problem is obvious–the explosion in number of hand sanitizer stations in public places–virtually everywhere you look. Given the pandemic, this is necessary and good. Many of these stations are placed about 3 feet above the floor which is right at eye level for younger children and the most common course of action is that the child rubs his hands still moist with ABHS into his eyes, resulting in injury.

Some suggestions to protect your child:

1. As with everything–vigilance. When in public places like malls be aware of ABHS station locations and keep young children away from them
2. Of course at home keep these products out of reach of small children.
3. Do not allow children to play with ABHS dispensers.
4. Endeavor to clean children’s hands with traditional soap and water as opposed to ABHS as much as possible.
5. If you do use ABHS on your children’s hands, you apply and rub in thoroughly until dry.
6. If ABHS does get into your child’s eyes, IMMEDIATELY rinse vigorously with water for up to 15 minutes. Do not wait to see if there is pain or evidence of trauma. Delay can allow injury to worsen.
7. If after that time frame your child still complains of sharp pain promptly seek medical attention.
8. As a public safety matter, popular venues should endeavor to place ABHS dispensers higher up, above the eye level of young children. Ideally, a warning sticker should be displayed at each site.

Although it is outside the scope of my blog, as an animal lover please allow me to point out that ABHS is NOT to be used on your pet. If they chew the bottle and swallow it, that can be highly toxic. ABHS should not be placed on animal’s skin and in particular not on its mouth, nose, or, of course, its eyes. Contact your veterinarian promptly if your pet is exposed to ABHS in that way.

Send along questions and comments, and thanks for following.

Screen use and covid

Covid grinds on. Several “new” developments provide hope–new vaccine, new year/new administration bringing new leadership/fresh eyes viewing the problem with new ideas and new energy to fight this scourge. We must renew our commitment to common sense practices–masks, hand washing, social distance, small, mostly outside groups.

Unfortunately, new challenges continue to develop as well. Child health providers note with great concern dramatically increasing online/screen use among young people; many parents have sensed this instinctively. This is a serious problem. Studies show a clear association between screen overuse in children and mental health problems like depression, anxiety, sleeplessness, impulsivity, school failures. Pediatric health providers in virtually all settings–private offices, outpatient clinics, ER’s– have witnessed a dramatic increase in these disorders presenting this past year.

Forgive me if this starts to sound somewhat like a sermon. The virus will not disappear miraculously and this problem isn’t cured with vaccines. It’ll take hard work, commitment, and sacrifice by all those responsible in children’s lives. Truthfully, we won’t “cure” screen overuse, but we can manage it more effectively. We pediatricians recommend MAXIMUM 1-2 hours/day total screen time(excluding school work)–games, social media, texting, viewing videos. Given “blue light” effect on sleep patterns, I advise discontinue screen use within 1 hour of bedtime.

We cannot “just say no,” — its essential to provide “yeses”–alternative activities for kids. This means effort by parents to engage with their children. Sacrifice? I suppose. But I am talking about playing with your kids. That’s mostly fun–right? Some suggestions:

1. Read! Encourage your children to read books/periodicals. Do it together. Read to your children<10 years–studies show it strengthens reading/vocabulary/intellectual development. Let your children see you reading for pleasure yourself.
2. There are innumerable board games (some from my childhood or before!)–Monopoly, Clue, Life.
3. Card games, dominos, jacks, tops–old school games that even develop fine motor or math skills in youngsters. Checkers and chess (chess goes back 1,000 years!)
4. Magic tricks–learn/teach/perform them for each other. Card tricks. There are local businesses that sell kits.
5. Musical instruments. Not for everybody, but this can be a lifelong hobby, even a career for some children. Private lessons are great; most school systems still teach musical instruments. You parents can take lessons too! Kids can form groups, families can play together–limitless possibilities.
6. Bowling, pool, ping pong–with friends or family
7. Lots of outdoor activities–take walks, bike rides, play catch, basketball. There’s golf, tennis, riding(lessons together?)

Admittedly, some of these activities require expense that may be beyond some families’ budget. But if you can afford it, you can consider it an investment in getting the kids off the computer. Speaking of “off the computer”: today’s young parents are the first generation to raise children having themselves grown up in the home computer age. Getting your kids off the computer requires that you look carefully at your own screen use. In fairness, you can’t get your child off the computer if you are overly absorbed yourself.

We all have responsibility to address this problem and we can effect positive change. Let’s get to work!

Thanks for following.

Youth Sports Participation after Covid

The American Academy of Pediatrics recently updated its guidelines, originally issued in July, regarding return to youth sports after covid infection. This revised position was strongly influenced by input from the American College of Cardiology as more data has become available thanks to ongoing research.

The recommendations basically divide these patients into 3 groups. Those with no or mild symptoms (such as those associated with any typical viral upper respiratory infection)–low grade fever (<102), of short duration (3-5 days), mild cough and typical only mild aches/pains may return to sports within 3-5 days of resolution of those problems when the child feels well. In particular this applies to children < 12 years of age, who’s sport activity level is mostly in line with the energy expenditures of everyday outdoor play.

Skipping ahead for a moment to “group 3,” this mostly includes those unusual children with severe symptoms requiring hospitalization for such problems as severe chest pains, shortness of breath requiring oxygen supplementation, signs/symptoms of pneumonia and other more dangerous problems. All of these children require thorough evaluation by a pediatric cardiologist prior to resumption of vigorous physical activity. Fortunately, most children DO NOT fall into this group.

It’s the middle group that presents more of a challenge. This includes children who have moderate symptoms of prolonged fever (> 5 days), more pronounced weakness/malaise, and in particular those children with more disruptive coughing (night time awakening, shortness of breath), and chest pain. This classification of post-infected children should refrain from all sports for at least 2 weeks after resolution of symptoms and have a baseline EKG prior to return. Depending on those findings, cardiology evaluation may be indicated.

Covid infection has been shown to cause injury to the heart muscle (“myocarditis”) which can lead to severe weakness and, in rare instances, serious heart rhythm disturbances, so these more significant symptoms must be assessed to evaluate for that problem. At this time, it is simply unknown if post-covid myocarditis is permanent or not; more time and study will be necessary to answer this important question.

I will re-emphasize that the large majority of covid infected children fall into category 1–no or mild symptoms-and have NO RISK for myocarditis. If you have any questions or concerns for your child after covid infection please be sure to bring them to my attention.

The AAP recognizes the physical and mental health advantages of youth sports–particularly in the midst of a pandemic–and strongly encourages participation wherever possible. Here are CDC guidelines to consider when deciding if sports participation during the pandemic is appropriate for your child.

Thanks for following.

Update: Medications and Side Effects

I recently read 2 medical articles regarding drugs and side effects; I have touched on that subject frequently. We are lucky in the modern world to have many treatments available to address all kinds of medical problems that our ancestors had to simply endure. However in reality each drug does have inherent risks; it’s imperative to use them in a cautious, thoughtful way. The 2 articles looked at 2 very commonly prescribed medications–antibiotics and steroids.

The 1st study found a significant correlation between antibiotic use with subsequent acute appendicitis. In 1.4 million children and 12,000 cases of appendicitis, the results were striking: a relative risk of 1.72–almost double — after one course of antibiotics. There were 3 other important findings: greater risk with “broad spectrum”(ie, more potent) antibiotics, a steadily increasing risk with each additional course of antibiotic treatment, as well as additional risk to children treated < 6 mo of age. The authors point out that this study only chronicles an “association”–they did not establish an exact “cause and effect” relationship, nor any specific mechanism to explain the association. But the data is clear, and troubling.

The second article looked at almost 2.5 million young, healthy adults receiving short courses of oral steroids and found a significant risk of GI bleeding, heart failure, and blood infections(sepsis) in those patients in the month after treatment compared to the 3 months prior. While not specifically looking at children, these young adults developed problems well known as risks of steroids, so “cause and effect” is well established here–what is new is the high risk of complications with even very short course of treatment.

Previously I’ve referenced articles noting the tendency of urgent care centers to overprescribe antibiotics. While that article did not mention steroids, my personal observation over the course of 35 years in practice is that unfortunate trend of too liberal prescribing holds for steroids as well. We should note that, with steroids, there are usually good, safer alternatives–including inhaled or topical forms, other safer non-steroidal drugs, and–not infrequently–no medicine at all.

In the world of covid, going to the ER or urgent care center must be measured carefully against the risk of exposure to serious infections there. My office now offers covid PCR testing (most insurance covers the cost) that has shown to be approximately 90% accurate. The turnover is usually +/-24 hours; those tests with faster turnover times tend to be less reliable. Usually, its safe to wait for regular office hours to assess your child’s condition and send the more accurate test from there. As we know, there is no specific treatment for covid anyway.

So give me a call if you are concerned about corona. We can address the issue together, decide if testing is appropriate, avoid unnecessary exposure (we usually do the testing right in the parking lot!), and, I am confident, avoid overprescribing for your child as well. Of course, in the event that the situation seems potentially more serious when we talk, I’ll help you there as well.

Thanks for following

Child Sleep Patterns

With the birth this week of beloved grandson #3–August Fels Geneslaw, 6 lb 5 oz–I’m thinking again of the new parents’ eternal lament: sleep disruption while their infant/young toddler establishes nighttime routines. Additionally, I spoke with a good friend, a former patient now grown, also a Mom and an ancillary healthcare professional herself, who was “heartbroken” for her friend going through just the above with her own new baby.

Frustration and fatigue are universally understandable. That fear, thankfully, is usually misplaced.

A recent study from the Journal Sleep Medicine of almost 6000 children followed over their first 2 years found significant variability in sleep patterns through much of that life phase. <6 mo many children took > 20 min to fall asleep. 40% of parents stated that their 8 mo old still had not established a consistent night routine; many still took > 45 min to fall asleep and/or had extended wakefulness in the “wee hours.” By 12 mo most toddlers will take < 45 minutes to fall asleep; 18 mo olds by 1/2 hr. Most 2 year olds had consistent night routines but STILL often with at least one late night awakening.

The important point is that these patterns are NORMAL. If your child’s growing along his curve, generally eating well, establishing regular eliminating patterns, that points towards good overall health. Appropriate developmental milestones are certainly important: young infant smiles, tracks, picks head off table when prone, brings hands together; older infants roll over, sit, babble, use hands; toddlers stand, cruise, feed self, begin simple words or gestures. If most of these things are happening on schedule(note: there is considerable variability here)then the sleep difficulties likely will work out eventually as well.

How to address problems depends on the particular child, age, the parents, and family dynamics. Certain basic principles do apply. A calm, consistent approach to bedtime and late awakening is essential: avoid becoming upset or angry. From very early, establish routines (do a, b, c) before bedtime: get into pajamas, lower ambient light, cool the room; avoid stimulating activity–quiet reading, singing is better; endeavor to learn even young infant’s cues of tiredness so you can initiate the sequence at the opportune time; in more difficult situations it is reasonable to let young children sleep NEXT TO parent(on the floor, in a day bed) but we pediatricians encourage parents to not bed share if at all avoidable.

When to give up/give in is tougher. Generally by 6 mo parents can regularly check a crying baby, allowing her to develop “self soothing” activities to drift off. But, again, variability is the rule. If your child cannot fall to sleep, nighttime awakening is increasing(especially older infants and toddlers), developmental milestones seem problematic and/or consistent elimination patterns are a struggle then there may be cause for some concern. NOTE: this applies to children in good health. “All bets are off” during or immediately after acute illnesses like the flu. Those disruptions should be temporary, however.

If you have concerns with the above, please give me a call so we can discuss. Thanks for following.

Vote for Kids

Today’s blog post, with < 40 days to the election, covers a topic that the American Academy of Pediatrics considers of vital concern for your child’s health–voting. It is your most basic right and responsibility as a citizen to have your voice heard on issues of public policy and how they impact your family’s well being.

To those who know me personally I am not the least hesitant to promote my preferred candidates but I certainly will NOT engage in that type of naked politicking here. Rather I will concentrate on 2 factors. Firstly, be sure to register and vote. NJ has pledged to mail ballots to all registered, active voters by Oct 5. READ IT CAREFULLY; fill it out properly. The rules are specific–postmarked by Nov 3, received by county clerk by 8pm Nov 10. If your ballot misses any requirements likely it will not be accepted and your vote not counted. If you are unsure of your registration status, go to vote.org where you can check, register or even apply for a mail in ballot. Please note that there is no early in person voting in NJ. More questions? Call NJ Secretary of State office at 1-609-292-3760.

Secondly, while I do not advocate for any candidate here, I fully support the AAP “Vote for Kids” initiative. To summarize some AAP positions on important policy questions as they impact the lives of children:

1. Healthcare insurance–we favor expanded access to Medicaid and Children”s Health Insurance Program(CHIP) and generally oppose provisions that may interfere with access–block grants, asset tests, work requirements, drug screens. All “waiver” applications should at least “do no harm” –to limit access, coverage, eligibility, or the basic list of covered services established by the Affordable Care Act.
2. Climate–We find that climate change is a legitimate public health crisis and the excessive burning of fossil fuels is a particular danger for children–from asthma and chronic lung diseases, to increases in low birth weight, premature infants; it contributes to IQ loss, attention, learning, and sleep disorders, and has numerous other neurotoxicities.
3. Environmental toxins–From heavy metals like lead and mercury to insecticides like chlorpyriphos, we favor policies to limit these agents’ release into the air, water, and soil. This is a particular hazard to pregnant women and unborn babies. The American College of Obstetrics and Gynecology states that “reducing exposure to toxic environmental agents is a critical area of intervention for reproductive health professionals” and calls for “timely action to identify and reduce exposure to toxic environmental agents.”
4. Guns- Every day 87 children are injured or killed by gun violence. AAP supports 2nd Amendment rights, but advocates for a vigorous scientific approach informed by research to keep children safe from gun violence. We support legislation for strong background checks, safe storage, assault weapon bans, and to prevent firearm trafficking, as well as $50 million to NIH and CDC for gun violence prevention research.
5. LGBTQ–AAP policy is that these youngsters have a RIGHT to comprehensive, gender affirming, developmentally appropriate healthcare(including mental health), that insurance cover the specific health needs of these children; we advocate for schools and community groups to promote inclusive and accepting policies, prevent bullying, for laws that prevent discrimination and violence, as well as for equal employment opportunities for LGBTQ people.

Groucho Marx famously quipped, “these are my principles–if you don’t like them, I have others.” These are some of the policies that we at the AAP identify as the best way to insure healthy children receive the promises of our great country. So many brave Americans fought and died to secure that right–the vote– for all of us.

Honor their service–get out and “Vote for Kids.”

Flattened Infant Heads

SIDS research has raised awareness about the importance of proper sleep technique: no “co-sleeping”(baby sleeps in crib NEXT TO, not in bed with parents), NO smoking in the house (PERIOD), flat spare crib without fluffy pillows, covers, bumper pads, and baby sleeps on back. “Back to Sleep” principles have, since, 1994, decreased the incidence of sudden infant death syndrome by 40%.

As a result of sleeping supine, some parents will note a flattening or irregular shaping of the back of baby’s head. This is called positional brachiocephaly or plagiocephaly. Usually, the occiput (back of the head) will flatten symmetrically and can be seen best looking from the side. In some instances, the head shape will distort more on one side than the other, which can be seen best by noting asymmetrical ear positioning while looking down at the top of the baby’s head.

Most typically, this is a completely benign situation and has no effect on brain development whatsoever. The “fontanelle”(soft spot) remains open, soft, flat, and nontender, which means there is plenty of room for the brain to grow. Most of the time, the problem will correct itself as the baby becomes more mobile and can reposition himself while asleep. so nothing MUST be done. Parents can take steps to correct or prevent brachi/plagiocephaly. Do “tummy time” play. Endeavor to carry your baby upright as opposed to in infant seat while you are out and about. Reposition her head from side to side periodically while very young infant is sleeping.

I do not recommend helmets as therapy. While they do seem to afford some head shape correction(especially if begun <6 mo old), most studies indicate that they have no real long term effects. In other words, whatever improvements achieved by the helmet were likely going to happen anyway; they would just take a few months longer. As such, in my experience, health insurance usually does not cover the cost as they consider it temporary and purely cosmetic. Given the evidence, its hard to disagree with them in this instance.

Craniosynostosis is an unusual, more serious (but treatable)problem, caused by a genetic defect that results in the fontanelle closing early before first year brain growth has completed. This can dangerously interfere with normal brain development. These children demonstrate early rapid head growth, often with more pathologically unusual head shapes. The best thing parents can do to address this problem is come in for well check up appointments, when your pediatrician will chart head circumference on a graph; we pediatricians are trained to differentiate the subtle differences between innocuous brachi/plagiocephaly and more alarming craniosynostosis.

Your baby’s check ups are more than shots and “green vs yellow veggies.” Be sure to keep up with them.

Send along questions and comments, and thanks for following.

Flu and Covid

With Labor Day approaching we should focus somewhat on influenza season/shots. I have previously commented on this regularly at this time of year. With covid now it’s critical for every eligible person to be vaccinated.

Last year approximately 34,000 US residents died from flu (169 children). This is better than in years past(2017-18: 61,000 fatalities),  likely due to yearly variation but also the effects of social distancing from covid which, recall, commenced in mid-March during the latter stages of 2019-20 flu season. New Jersey suffered approximately 1300 deaths.  There were perhaps 40-60 million US cases with almost 740,000 hospitalizations(78/100,000 population). Nationally immunization rates approximate 45% of total population but the rate in the essential 18-50 age cohort is unfortunately lower. About 58% of children are immunized annually, and, thankfully, 81% of healthcare workers get their flu shots.

Most people are eligible for flu immunization:

• 6mo-9 years need a second  shot >30 days after their first if it’s their first year being immunized. In subsequent years only one shot is needed in that age group that year. < 6 mo are ineligible. Therefore, all household contacts and caregivers for <6mo infants should be immunized for baby’s protection. There are some reports of very small risk of febrile seizure in young children receiving DTaP and flu shot simultaneously, however, the data is inconsistent(some say yes, some no) and even among the positive reports there was no evidence of long term harm to any child in that affected group.
• People with chronic illnesses like asthma, diabetes, heart disease, or neuromuscular disorders need their flu shot.
• Immunosuppressed people, like cancer chemotherapy patients should definitely be immunized, although with “inactivated” vaccine only–NOT “Live, attenuated” vaccines.
• Pregnant women should be immunized. Side effects are mild and infrequent, essentially the same as non-pregnant women; serious side effects are extremely rare. Hospitalization rates during pregnancy are lowered approximately 40% by immunization, and infants born to immunized mothers contract influenza 63% less in their first 6 months (recall, they are ineligible to be immunized at that young age)
• Egg allergic patients can be immunized safely if they only had mild allergy reactions like hives as opposed to anaphylaxis.  In between reactions should consult an allergist first.

We all witnessed with horror as corona gripped the tristate area this past early spring and with similar dismay as it rolls across various states and regions now. I witnessed first hand how it devastated our local hospitals and, as the father of a NYC based ICU pediatrician, know from first hand reports how City hospitals were pressed to the breaking point and beyond with ER, inpatient, and ICU admissions for corona.  Most authorities predict increased covid activity as the weather chills, so it’s imperative that every eligible person gets his/her flu shot this year so that we don’t create a public health crisis, with hospitals overwhelmed by corona, flu, and combined cases. That scenario puts literally everyone at greater health risk.

Our flu shots are in, please call to schedule for your child. I urge everyone to get immunized: protect your community, your loved ones, and yourself.

Thanks for following.