Asthma Policy Purpose To outline requirements for Asthma Scope All operational levels of Life Saving Victoria Policy Introduction Bronchial asthma or wheezy bronchitis, is a common condition within the community and may affect all groups from infancy to advanced old age. In its most severe form it requires hospitalisation in an Intensive Care Ward but in its milder form does not prevent sporting competition at the highest level. There are several examples of world and Olympic champions who have suffered asthma for years and whose case histories have been described in Medical Journals. There is considerable evidence that exercise is very helpful in the overall management of people with asthma1. A history of asthma by itself should be no deterrent to participation in any aquatic activity including teaching, being taught, examining, competing, or practical lifeguarding providing the lifeguard or student concerned is following the advice of a medical practitioner who is fully conversant with the implications of these activities. Asthma is a very variable condition and LSV recognises that a lifeguard with asthma may be fully fit at some times but not fit for various lifeguarding activities at other times. The responsibility for the
Hc.ufpr.brTreatment, and Neisseria meningitidishas recently emerged as the leading cause of meningitis in children and young adults in the United States (Centers for Disease Control and Prevention [CDC], 2000). The average annualrate of invasive disease such as meningitis, meningococcemia, and Neisseria meningitidis is a leading arthritis is approximately 1.1 cases per 100,000 population, or 2600 cases cause of meningitis and septicemiain children and young adults in the per year (Estabrook, 2000). Approximately 20% of patients with United States. Highly publicized meningococcemia die, and approximately 5% of patients with meningo- outbreaks of disease caused by this coccemia with meningococcal meningitis die (Edwards & Baker, 1999).
organism in communities and on Because of widespread use of an effective vaccine, invasive disease college campuses have resulted in resulting from Haemophilus influenzae B is now exceedingly rare. Vac- a heightened public awareness of cines for Streptococcus pneumoniae also are available with the hope that its potentially devastating effects.
the incidence of disease caused by susceptible strains will show a simi- The rapid progression of signs and lar sharp decline. Thus, the relative frequency of disease caused by N symptoms of meningococcemia meningitidis is likely to increase.
necessitate early recognition and Highly publicized outbreaks of diseases related to N meningitidis in institution of appropriate therapeu- communities and on college campuses have resulted in much public con- tic measures. Identifying contacts ofindex cases who are at high risk of fusion about how best to prevent and treat disease related to this organ- acquiring the disease allows health ism. The purpose of this article is to discuss the epidemiology, primary care providers to institute appropri- and secondary prevention, diagnosis, and acute management of menin- ate chemoprophylaxis. Duringcommunity outbreaks, health careproviders play an equally important Laura E. Ferguson is Assistant Professor of Pediatrics, University of Texas–Houston Medical School.
role in calming the fears of low-risk Mark D. Hormann is Assistant Professor of Pediatrics, University of Texas–Houston Medical School.
contacts and their families. Famil- Deborah K. Parks is Associate Professor of Pediatrics and Director, Division of Nurse Practitioners/Physician iarity with the risks and benefits of Assistants, University of Texas–Houston Medical School.
the meninogococcal vaccine allows Robert J. Yetman is Professor of Pediatrics and Director, Division of Community and General Pediatrics, Uni-versity of Texas–Houston Medical School.
health care providers to offer this Reprint requests: Robert Yetman, Department of Pediatrics, University of Texas Medical School at Houston, immunization to appropriate 6431 Fannin, Suite 3140, Houston, TX 77030.
Copyright 2002 by the National Association of Pediatric Nurse Practitioners.
J Pediatr Health Care. (2002). 16, 0891-5245/2002/$35.00 + 0 PH ORIGINAL ARTICLE Ferguson et al.
gitis and meningococcemia caused by degree of generalized health concern.
direct exposure to the index patient's N meningitidis. Careful case definitions are important oral secretions), (b) exposure to a high- to identify others who are at risk for the risk contact of the index patient without condition and to allay public concern.
direct contact with the index patient The N meningitidis organism is trans- The definition of a confirmed invasive himself or herself, and (c) exposure to mitted by means of respiratory drop- meningococcal disease includes isola- the index patient by medical personnel lets from carriers. Humans are the only tion of N meningitidis from blood, cere- who have not had direct exposure to known natural reservoir. Carriage rates bral spinal fluid, or other typically ster- the index patient's oral secretions.
vary from 95% during group A epi- ile fluid. Presumptive cases are those in demics to 50% among military recruits which gram-negative diplococci are to about 10% among the randomly identified in any typically sterile body sampled population (Hughes & Le- fluid. Probable cases are identified in the pow, 1999). The carrier rate is typically setting of a clinical illness that is con- A 15-year-old white girl who lives in a higher where crowding occurs, such as sistent with meningococcal disease large suburban community near Hous- on military installations, in prisons, at with positive results of antigen tests ton, Texas, complained to her mother sporting events, and in dormitories but without a positive culture from about a subjective fever. She took aceta- (Hughes & Lepow, 1999). Increased body fluid normally found sterile minophen and went to sleep. The next carriage rates are also associated with (American Academy of Pediatrics morning her mother found her lying smoking, upper respiratory tract infec- [AAP], 1996). A patient with con- on the floor of her bedroom; she was tions, influenza, and tonsillectomy firmed, presumptive, or probable unresponsive. She apparently had (Hughes & Lepow, 1999).
meningococcal disease on the basis of been vomiting and a purplish rash had In the United States, about 90% of these definitions is considered an developed on her upper extremities.
meningococcal disease is caused by Paramedics took her to a nearby hos- serogroups B and C. Group B disease is pital, where she was noted to have a more often sporadic, whereas group A Definition of Exposure
temperature of 105°F and to be hypo- The media attention surrounding a sin- tensive. Normal saline solution bolus- gle case of meningococcal disease in a es were administered, along with dopa- community often results in scores of mine, norepinephrine, vancomycin, telephone calls to health care providers ceftriaxone, and penicillin. Further The N meningitidis by concerned patients and families extension of her rash was noted. She
who are questioning their risk of con- was transported immediately via Life- organism is transmitted by
tracting the disease. Thus, identifying Flight helicopter to Memorial Her- children who are at high risk for the mann Children's Hospital and was means of respiratory
disease and who require antimicrobial admitted directly to the pediatric ICU.
prophylaxis is imperative.
Upon admission she was noted to droplets from carriers.
Patients at high risk for contracting have purpura fulminans, hypotension, meningococcal disease include house- disseminated intravascular coagu- hold contacts (especially young chil- lopathy, and respiratory failure. The dren), persons in day care or nursery patient was intubated emergently, and and C disease is more likely to be epi- school who have been exposed to an antibiotics and pressors continued to demic (Hughes & Lepow, 1999). The index case within 7 days, persons with be administered. The presumptive highest attack rates occur in the winter direct exposure to the secretions of an diagnosis of meningococcemia was or early spring (Estabrook, 2000). Al- index case (eg, through kissing, shar- made based on her presentation, but it though rare but well-publicized out- ing toothbrushes, or sharing eating was never proven by culture. Her breaks of meningococcal disease oc- utensils), or persons who have been hospital course was complicated by cur on college campuses, about 46% frequently exposed to an index patient hypertension, gram-negative sepsis, of cases occur in children younger by eating or sleeping with the patient.
fungemia, and acute renal tubular than 2 years, with another 25% of Also included in the high-risk catego- necrosis requiring dialysis. Necrotic cases occurring in patients older than ry are health care professionals who tissue developed in her upper and 30 years (Estabrook, 2000; Hughes & have been exposed through mouth-to- lower extremities, and although graft- Lepow, 1999). Fifty-eight percent of mouth resuscitation or unprotected ing was attempted, she ultimately patients who have invasive meningo- contact during endotracheal intuba- required bilateral below-the-knee am- coccal disease present with meningi- tion within 7 days before the onset of putations and bilateral upper ex- tis (Estabrook, 2000).
the illness (AAP, 1996). Nasophar- tremity amputations. In addition, she yngeal cultures are of no use in deter- required a diverting colostomy for Definition of a Case
mining who should receive prophy- wound healing and a gastrostomy Periodically the media report that "a laxis (AAP, 2000).
tube for nutrition. The length of her case of meningitis" has been found in a The vast majority of exposures are initial hospitalization was 90 days. She community. This announcement is considered low-risk exposures. Low- continues to receive rehabilitation ser- rarely specific enough to determine risk exposures include (a) casual con- vices as she recovers from the compli- either the offending agent or the tact with an index patient (without cations of her disease.
Volume 16 Number 3 JOURNAL OF PEDIATRIC HEALTH CARE PH ORIGINAL ARTICLE Ferguson et al.
This case illustrates a complicated than 20 mm/h, metabolic acidosis with resuscitation is critical, fluid overload course of meningococcal disease. The a pH less than 7.3, a cerebrospinal fluid in patients with meningitis may lead to sudden and severe presentation, cou- (CSF) white blood cell count less than cerebral edema; monitoring for evi- pled with the possible long-term seque- 100/mm3, and positive blood cultures dence of increased intracranial pres- lae, is frightening to patients, families, (Hughes & Lepow, 1999).
sure is mandatory in these patients.
and providers and contributes to much Some patients may require use of vaso- misunderstanding in the diagnosis, treat- pressors such as dopamine to maintain ment, and prevention of this disease.
Aggressive management in an ICU adequate blood pressure and perfusion.
optimizes outcomes for patients pre- Purpura fulminans, a consequence of senting with presumed meningococ- severe disease with disseminated intra- Invasive meningococcal disease (men- cemia. The airway must be main- vascular coagulation, is treated with ingococcemia, meningitis, or both) can fresh frozen plasma, blood, and possi- present with the classic findings of bly platelets. The total volume of these abrupt onset of flulike symptoms products contributes to the total fluid including fever, chills, malaise, vomit- required for resuscitation (Estabrook, ing, prostration, drowsiness, disorien- 2000; Frankel, 2000).
tation, hallucinations, convulsions, andan urticarial, maculopapular, or pete- Diagnosis and Treatment
chial rash. Rapid progression over sev- Diagnostic lumbar puncture, while eral hours leads to purpura, dissemi- useful in determining the extent of dis- meningitis, or both) can
nated intravascular coagulation, shock, ease and its prognosis, is not essential coma, and death resulting from Water- for determining the appropriate thera- present with the classic
house-Friderichsen syndrome (adrenal py. Unlike sepsis or meningitis caused hemorrhage) (AAP, 2000; Estabrook, by pneumococcus, H influenzae, or 2000; Hughes & Lepow, 1999). The findings of abrupt onset of
other bacterial pathogens where the signs and symptoms of meningitis dose of antibiotics is higher for patients resulting from N meningitidis cannot be flulike symptoms including
with meningitis, all disease known to distinguished from those caused by be caused by N meningitidis is treated pneumococcal disease, H influenzae B fever, chills, malaise,
with penicillin G at the recommended (especially in small, unimmunized chil- dose of 250,000 IU intravenously per dren), Rocky Mountain spotted fever, dose given every 6 hours for 7 days or other rickettsial disease. Milder ill- (AAP, 2000; Estabrook, 2000; Hughes & nesses such as atypical measles may Lepow, 1999). Lumbar punctures are also present with a petechial rash and not attempted in patients who are fever (AAP, 2000; Estabrook, 2000; hemodynamically unstable, have evi- Hughes & Lepow, 1999).
dence of increased intracranial pres- Rapid recognition of the clinical fea- sure, or who have an unstable airway tures is imperative; abrupt onset of ill- convulsions, and an
(Anderson, Glode, & Smith, 1998; ness in any previously well child or Estabrook, 2000).
young adult prompts the practitioner If meningococcemia is suspected, a to consider N meningitidis in the differ- complete blood cell count and blood ential. Patients with milder signs of ill- or petechial rash.
culture are obtained, if possible, ness not obviously attributable to before empiric therapy is initiated. A meningococcemia are observed closely urine latex agglutination for N menin- by parents or health care practitioners gitidis may be helpful for patients to differentiate the rapidly progressive tained, especially in obtunded patients, who received emergent treatment course of meningococcemia from more with an oral airway or with intubation before a blood culture was obtained, common viral illnesses. If the patient and artificial ventilation. Symptoms of although testing for serotype B is asso- begins to deteriorate, treatment of the impending shock, such as tachycardia, ciated with low sensitivity and speci- impending shock is initiated.
poor perfusion, hypotension, and olig- ficity (Anderson et al., 1998). Similar- Poor prognostic clinical indicators uria, are treated with normal saline ly, a latex agglutination performed on for a patient with meningococcemia solution or lactated Ringer's solution.
the CSF may be helpful for patients include rapid dissemination of the pur- Small children may receive boluses of who received antibiotic therapy prior puric rash, shock, hypotension, coma, these fluids at 20 mL/kg; larger chil- to lumbar puncture. acute onset of seizures, and absence of dren may be resuscitated with use of meningeal signs in very young or very body surface area calculations or can old patients (Hughes & Lepow, 1999).
be started empirically on 1 L of fluid Patients known to have infection Laboratory features consistent with over 20 minutes. Adequacy of resusci- caused by N meningitidis are treated poor prognosis include a white blood tation is evaluated by ongoing obser- with a recommended dose of 250,000 cell count less than 10,000/mm3, an vation of perfusion and monitoring of IU of penicillin intravenously per dose erythrocyte sedimentation rate less vital signs continually. Although fluid given every 6 hours for 7 days. Men- JOURNAL OF PEDIATRIC HEALTH CARE PH ORIGINAL ARTICLE Ferguson et al.
loss. Other less commonly reported BOX Partial differential diagnosis for meningococcemia
complications include immune-relatedarthritis, myocarditis, pericarditis, atax- ia, seizures, blindness, cranial nervepalsies, hemiparesis or quadriparesis, and obstructive hydrocephalus (Esta- • Viral meningitis brook, 2000). Pneumonia, conjunctivi- • Echovirus (types 6, 9, 16) tis, and chronic meningococcemia with • Coxsackievirus (A2, A4, A9, and A16) rash, fever, arthritis, and arthralgia also occur infrequently (Edwards & Baker, 1999; Hughes & Lepow, 1999).
• Atypical rubeola Nonviral infectious agents • Bacterial meningitis (pneumococcal, H influenzae)• Mycoplasma• Leptospirosis• Syphilis Patients known to have
• Septicemia resulting from gram-negative organisms or overwhelming septicemia infection caused by N
resulting from gram-positive organisms • Bacterial endocarditis • Epidemic typhus• Rocky Mountain spotted fever• Ehrlichiosis with a recommended dose
• Scarlet fever of 250,000 IU of penicillin
• Encephalopathies (variety of causes)• Acute hemorrhagic encephalitis intravenously per dose given
• Serum sickness• Henoch-Schonlein purpura every 6 hours for 7 days.
• Various poisons• Erythema multiforme or erythema nodosum resulting from a variety of • Immune thrombocytopenic purpura • Kawasaki disease • Systemic lupus erythematosus and other febrile mucocutaneous diseases Medications for Prophylaxis
Data from AAP, 2000; Estabrook, 2000.
After an index case has been identified,prophylaxis of high-risk contacts isindicated. A variety of medications ingococcemia may be one of several influenzae B infection (such as those with variable efficacies are available diagnoses entertained by the practi- incompletely immunized or unimmu- (Table). The age of the patient and the tioner faced with a gravely ill patient nized or in areas of high risk) often route and ease of administration of the with fever, mental status changes, and receive dexamethasone prior to admin- medication play a role in determining a petechial rash (Box). Therefore, em- istration of antibiotics in an effort to which medication is chosen. Because piric therapy for N meningitidis with avoid central nervous system sequelae.
secondary cases of meningococcemia ceftriaxone (for pneumococcus and H Use of steroids in N meningitidis dis- can occur weeks after the index case influenzae B) and vancomycin (for resis- ease remains unproven and controver- has been identified, meningococcal tant streptococcal strains) may be pru- sial (Estabrook, 2000).
vaccine can be considered as part of the dent while awaiting results of urine or For patients who have negative cul- prophylaxis if the causative strain is in CSF latex agglutination, CSF gram tures and/or latex agglutination for N the vaccine.
stain, and blood culture testing (AAP, meningitidis but who have petechial The goal of antimicrobial prophylax- 2000; Estabrook, 2000; Hughes & rash and significantly altered mental is is the eradication of any nasopharyn- Lepow, 1999). Patients with N meningi- status, illnesses including leptospirosis geal carriage of N meningitidis in con- tidis who are allergic to penicillin may and other vasculitides must be consid- tacts of the index case. The medications receive chloramphenicol. Tetracycline ered; appropriate therapy for these listed in the Table for chemoprophylax- for patients older than 8 years may be conditions should be considered.
is penetrate well into the secretions of considered if Rocky Mountain spotted the nasopharynx and thus eliminate fever is in the differential diagnosis colonization. By eliminating the organ- based on travel history or region of res- Ten percent to 15% of cases of invasive ism in close contacts of the case, the idence (AAP, 2000).
meningococcal disease are fatal. Of the spread of the disease is interrupted.
Children who are at high risk for H patients who recover, 10% have hearing The antibiotics commonly used to treat Volume 16 Number 3 JOURNAL OF PEDIATRIC HEALTH CARE PH ORIGINAL ARTICLE Ferguson et al.
TABLE Chemoprophylaxis medications for high-risk contacts and index cases
Orange urine; staining of contact lenses possible; can interfere with oral contraceptives, seizure medica-tions, and anticoagulants; avoid in pregnancy 10 mg/kg (max 600 mg) every 12 h, orally Mixed with 1% lidocaine to decrease injection pain 250 mg, intramuscularly Avoid in pregnancy Used with permission of the American Academy of Pediatrics, Red Book 2000: Report of the Committee on Infectious Diseases, 25th Edition, AAP, 2000.
meningococcal disease such as peni- other meningococcal group polysac- the high-risk group are patients with cillin often fail to eliminate nasopha- charides is poor. Groups Y, W-135, and functional or anatomic asplenia and ryngeal carriage; therefore, some ex- C induce antibody response after 2 patients with immune abnormalities perts suggest treating the index case years of age. To further complicate the such as alterations in their terminal with a medication that will eliminate issue, the need and timing of reimmu- complement component or properi- the nasopharynx colonization (Table) nization are not fully known (AAP, dine deficiencies. Travelers to endem- (Salzman, 1996).
2000). Fortunately, adverse effects of ic areas of the world should consider the vaccine are unusual and mild, including erythema at the injection site For college-aged children, the AAP Highly publicized cases of meningitis for 1 to 2 days.
recommends that health care providers caused by N meningitidis have focused Routine administration of the men- "…should inform and educate students attention on appropriate use of the ingococcal vaccine is not recommend- and parents about the risk of meningo- meningococcal vaccine, especially on coccal disease and the existence of a college campuses. Unfortunately, head- safe and effective vaccine and immu- lines such as "Campus meningitis pre- nize students at their request or if edu- ventable for $65" (Manning, 1999a) cational institutions require it for and "Freshmen face highest risk of admission" (AAP, 2000, p. 401). The dverse effects of the
deadly bacterial strain" (Manning, American College Health Association 1999b) do not fully explain the public and the Advisory Committee on vaccine are unusual and
health policy dilemma. A more com- Immunization Practices have similar plete understanding of the uses of the recommendations that advise college mild, including erythema
vaccine is indicated.
freshmen of an increased risk of The meningococcal vaccine, ap- meningococcal disease and the avail- proved for use in children 2 years of at the injection site for 1
ability of an effective vaccine (CDC, age and older, is a quadrivalent prod- uct effective against N meningitidis to 2 days.
When an outbreak or cluster of inva- groups A, C, Y, and W-135; vaccine sive meningococcal cases in a defined against group B disease is not avail- population is recognized, such as in a able. According to the AAP Red Book, particular school or community, vacci- the various components of the vaccine ed by the AAP. The rationale behind nation may be recommended by local are immunogenic at various ages this stance is that the infection rate is or state public health authorities if the (AAP, 2000). For instance, group A low, the response to the vaccine in strain causing the problem belongs to meningococcal vaccine is reported to younger children is poor, the immuni- one of the vaccine-preventable sero- be immunogenic in children 3 months ty achieved is relatively short-lived, groups; in general, a rate of more of age and older, but adult levels of and the response to additional vac- than 10 occurrences per 100,000 pop- immunogenicity are not achieved until cine doses is sometimes impaired ulation occurring within a 3-month ages 4 or 5 years; when the vaccine is (AAP, 2000). The vaccine is recom- will trigger prophylactic vaccination.
given in response to control epidemics mended for children 2 years and The state and local health authorities of group A disease, response to the older in high-risk groups. Included in will delineate the exact population JOURNAL OF PEDIATRIC HEALTH CARE PH ORIGINAL ARTICLE Ferguson et al.
subset selected to receive the vaccine.
strategies for practice-based physicians. Pedi-atrics, 97, 404-412.
Chemoprophylaxis for close contacts American Academy of Pediatrics. (2000). Men- may also be indicated as previously ingococcal infections. In L. K. Pickering (Ed.), described; vaccination in these cases apid identification of
2000 Red Book: Report of the Committee on Infec- can serve as an adjunct to provide tious Diseases (25th ed., pp. 396-401). Elk Grove longer-lasting protection (AAP, 1996; Village, IL: Author.
potential cases, knowledge
Anderson, M. S., Glode, M. P., & Smith, A. L.
(1998). Meningococcal disease. In R. D. Feigin of basic resuscitation
& J. D. Cherry (Eds.), Textbook of pediatric infec- tious diseases (4th ed., pp. 1143-1154). Philadel- Primary care providers have a re- phia: W. B. Saunders Company.
measures, and rapid transfer
Centers for Disease Control and Prevention. (1997).
sponsibility to be aware of the present- Control and prevention of serogroup C men- ing signs and symptoms of disease ingococcal disease: Evaluation and management to a facility with the
caused by N meningitidis and to rapid- of suspected outbreaks: Recommendations of the ly triage patients suspected of having Advisory Committee on Immunization Prac- capacity to adequately
one of these conditions to the nearest tices. MMWR, 46(RR-5), 13-21.
Centers for Disease Control and Prevention.
emergency department. Health care (2000). Meningococcal disease and college stu- providers are uniquely situated to pro- manage these patients are
dents. Recommendations of the Advisory vide accurate information during Committee on Immunization Practices (ACIP).
school or community outbreaks of dis- MMWR, 49(RR-7), 13-20.
necessary to maximize the
Edwards, M. S., & Baker, C. J. (1999). Meningo- ease caused by N meningitidis and have coccal infections. In J. A. McMillan, C. D.
the ability to help allay public anxiety DeAngelis, R. D. Feigin, & J. B. Warshaw (Eds.), that is invariably seen during such out- Oski's pediatrics: Principles and practice (3rd ed., breaks. Practitioners should be familiar pp. 980-984). Philadelphia: Lippincott Williams with case definitions of exposure to Estabrook, M. (2000). Neisseria meningitidis. In R. E.
disease caused by N meningitidis so that ity with the capacity to adequately Behrman, R. M. Kliegman, & H. B. Jenson (Eds.), appropriate postexposure prophylaxis manage these patients are necessary to Nelson textbook of pediatrics (16th ed., pp. 826- can be administered. Finally, primary maximize the outcome. Familiarity 829). Philadelphia: W. B. Saunders Company.
care providers will be a valuable re- with the definition of a case and a high- Frankel, L. R. (2000). Shock. In R. E. Behrman, R.
M. Kliegman, & H. B. Jenson (Eds.), Nelson text- source to parents and patients as they risk exposure, as well as the appropri- book of pediatrics (16th ed., pp. 262-266). Phila- weigh the pros and cons of routine vac- ate prophylactic treatment, can help delphia: W. B. Saunders Company.
cination for these bacteria.
reduce the near-hysterical public re- Hughes, P. A., & Lepow, M. L. (1999). Meningo- sponse seen during meningitis out- coccal disease. In F. D. Burg, J. R. Ingelfinger, E.
breaks. Providers should educate fam- R. Wald, & R. A. Polin (Eds.), Gellis & Kagan'scurrent pediatric therapy (16th ed., pp. 72-74).
The rapid onset and potentially devas- ilies about the risks and benefits of the Philadelphia: W. B. Saunders Company.
tating consequences of disease caused meningococcal vaccine, with a particu- Manning, A. (1999a, June 1). Campus meningitis by N meningitidis are frightening to lar focus on college-aged students.
preventable for $65. USA Today, p. D9.
patients, parents, and health care pro- Manning, A. (1999b, June 1). Freshmen face highest risk of deadly bacterial strain. USA Today, p. viders. Rapid identification of potential cases, knowledge of basic resuscitation American Academy of Pediatrics. (1996).
Salzman, M. B. (1996). Meningococcemia. Infectious measures, and rapid transfer to a facil- Meningococcal disease prevention and control Disease Clinics of North America, 10, 709-725.
NAPNAP's 24th Annual Nursing Conference
on Pediatric Primary Care
Gaylord Palm Resort and Convention Center Contact: Maureen Walker, A. J. Jannetti, Inc., (856) 256-2300 or visit the NAPNAP Web site (www.napnap.org) Volume 16 Number 3 JOURNAL OF PEDIATRIC HEALTH CARE
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