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Your Child

CDC, White House Urge Measles Vaccinations

2:00

In 2002, when measles were essentially declared eliminated in the U.S., scientists didn’t expect parents would begin to opt out of the MMH vaccinations for their children during the next 5 years. The vaccine is safe and effective, so who wouldn’t want their child protected from a painful and potentially fatal disease?

Turns out that there are American parents who fear vaccines and children who visit from other countries where the vaccine is not available, widely distributed or required for travel.  Measles hasn’t been eliminated around the world and has reared its ugly head again the states.

So far, more than 90 people have been diagnosed in California and the disease has spread to 13 other states including Arizona, Colorado, Illinois, Minnesota, Michigan, Nebraska, New York, Oregon, Pennsylvania, South Dakota, Texas, Utah and Washington as well as Mexico.

According to public health officials, the current outbreak has been linked to 58 cases that began when an infected person from outside the United States visited Disneyland in Anaheim between Dec. 15 and Dec. 20.

Dr. Anne Schuchat, director of the Centers for Disease Control and Prevention’s (CDC) National Center for Immunization and Respiratory Diseases, said a traveler could still easily bring in the disease from abroad.

"This is a wake-up call to make sure we keep measles from getting a foothold in our country," she said.

The measles vaccine is part of a grouping of vaccines known as MMH (measles, mumps and rubella.) These diseases spread from person to person through the air. They are highly contagious. You can easily catch them by being around someone who is already infected, but not showing symptoms.

The MMH vaccine can protect children (and adults) from all three of these diseases.

There are valid medical reasons why some people should not receive the vaccine that include:

·      Anyone who has had life-threatening allergic reaction the antibiotic neomycin or any other component of the MMH vaccine.

·      People who are sick at the time the vaccine is scheduled. They should wait till they recover before getting the vaccine.

·      Pregnant women should not get the vaccine until after giving birth. Women should avoid getting pregnant for 4 weeks after vaccination with the MMR vaccine.

·      People with compromised immune systems .You should tell your doctor if you have or are being treated for or with:

o   HIV/AIDS

o   Steroids

o   Cancer

o   A low platelet count

o   Have received another vaccine within the past 4 weeks

o   A transfusion or received other blood products.

The outbreak has renewed debate over the so-called anti-vaccination movement in which fears about potential side effects of vaccines, fueled by now-debunked theories suggesting a link to autism, have led a small minority of parents to refuse to allow their children to be inoculated.

Schuchat called it "frustrating" that some Americans had opted out of the vaccine for non-medical reasons, saying it was crucial that they be given good information about the safety and reliability of inoculations.

There is no specific treatment for measles and most people recover within a few weeks. But in poor and malnourished children and people with reduced immunity, measles can cause serious complications including blindness, encephalitis, severe diarrhea, ear infection and pneumonia and even death.

The White House said on Friday that parents should be “listening to our public health officials,” who urge vaccinations against measles, as it emerged the disease has now infected more than 100 people in the U.S.

White House Press Secretary Josh Earnest said that President Obama thinks parents should ultimately make their own decision whether or not to vaccinate their children, Reuters reports, but added that the science clearly points to vaccinating.

“People should evaluate this for themselves with a bias toward good science and toward the advice of our public health professionals,” said Earnest.

Measles is preventable. We live in a country where the MMH vaccine is affordable and easy to get. We’re fortunate that way.

Children should get 2 doses of MMH vaccine. The first dose when they 12-15 months of age and the second dose 4-6 years of age. Some infants younger than 12 months can receive a dose if they are travelling outside the United States. Children between 1 and 12 years of age can get a "combination" vaccine called MMRV, which contains both MMR and varicella (chickenpox) vaccines.

If you have any concerns about the MMH vaccine, talk with your pediatrician or family doctor about its safety and effectiveness. If you received the MMH vaccine when you were a child, you might want to consider a booster shot.

Sources: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmr.html

Dan Whitcomb, http://www.reuters.com/article/2015/01/30/us-usa-measles-disneyland-idUSKBN0L302120150130

Mandy Oaklander, http://time.com/3691079/measles-vaccinations-white-house/

Your Toddler

Uncut Grapes Can Choke Young Children

1:30

While good nutrition involves plenty of fresh fruits and vegetables, there’s one fruit that should not be given to children 5 and under; grapes.

Uncut grapes are dangerous for young children because their size and smooth texture can cause choking and even death.

There have already been three choking cases in Scotland, out of which two turned out to be fatal, involving boys who were 5 or younger.

A report published in the journal Archives of Disease in Childhood notes that food is responsible for more than half of the choking incidents, which end in deaths when it comes to children under the age of 5.

"There is general awareness of the need to supervise young children when they are eating ... but knowledge of the dangers posed by grapes and other similar foods is not widespread," noted Dr. Jamie Cooper, co-author of the report, from the emergency department at Royal Aberdeen Children's Hospital.

According to the same report, there is no awareness concerning the specific risks that soft fruits raise, and the relatively small numbers of cases per hospital, which occur every year, don't fully reflect the extent to which this issue can affect young children.

Kids that have choked on grapes don’t often make the news, but according to research conducted in the United States and Canada, grapes occupy third place when it comes to deaths caused by food-related incidents, after hotdogs and sweets.

There are two reasons why grapes are so dangerous, especially in very young children: first, because the airways of the children are small and their swallow reflex is not fully developed, and second due to the smooth texture of the fruit.

Other foods with similar texture can pose a choking hazard, such as tomatoes.  Health experts suggest that grapes and tomatoes be cut in half twice. Anytime a child (or an adult for that matter) is eating uncut grapes or small tomatoes they should pay attention to their eating and not mechanically pop them into their mouths – like when watching TV or playing video games.

Grapes and tomatoes are good sources of fiber and healthy nutrients, just make sure that your little one has his or hers’ cut up so they are not easily choked when eating them.

Story source: Livia Rusu, http://www.techtimes.com/articles/189851/20161224/grapes-as-a-choking-hazard-doctors-say-lack-of-awareness-puts-young-children-at-risk.htm

 

 

Your Child

Backpack Safety Tips for Kids & Parents

1:30

Backpacks have almost become a part of every student's uniform.  They’re not only filled with schoolbooks but often clothes, pencils and papers, notebooks, lunches, phones, computers and an assortment of other items.  All that stuff adds up in the amount of weight resting on your child’s back and shoulders.

When used correctly, backpacks can be a good way to distribute excess weight evenly. However, backpacks that are too heavy or are worn incorrectly can cause problems for children and teenagers. Improperly used backpacks may injure muscles and joints. This can lead to severe back, neck, and shoulder pain, as well as posture problems.

The American Academy of Othopaedic Surgeons (AAOS) has these backpack tips for helping your child avoid injuries and soreness from almost every day use.

Choosing the right backpack:

When choosing a backpack, look for one that is appropriate for the size of your child. In addition, look for some of the following features:

               ·      Wide, padded shoulder straps

•       Two shoulder straps

•       Padded back

•       Waist strap

•       Lightweight backpack

•       Rolling backpack

Injury Prevention:

To prevent injury when using a backpack, do the following:

•       Always use both shoulder straps when carrying the backpack. The correct use of both of the wide, well-padded shoulder straps will help distribute the weight of the backpack across the child�s back.

•       A cross-body bag can also be a good alternative for carrying books and supplies.

•       Tighten the straps to keep the load closer to the back.

•       Organize the items: pack heavier things low and towards the center.

•       Pack light, removing items if the backpack is too heavy. Carry only those items that are required for the day, and if possible, leave unnecessary books at home or school.

•       Lift properly by bending at the knees when picking up a backpack.

Tips for Parents:

Parents also can help.

•       Encourage your child or teenager to tell you about numbness, tingling, or discomfort in the arms or legs, which may indicate poor backpack fit or too much weight being carried.

•       Watch your child put on or take off the backpack to see if it is a struggle. If the backpack seems too heavy for the child, have them remove some of the books and carry them in their arms to ease load on the back.

•       Do not ignore any back pain in a child or teenager.

•       Talk to the school about lightening the load. Team up with other parents to encourage changes.

•       Encourage your child to stop at his or her locker when time permits throughout the day to drop off or exchange heavier books.

•       If your child has back pain that does not improve, consider buying a second set of textbooks to keep at home.

Backpacks are great for carrying school bound objects – they help kids keep organized and help prevent assignments and school information from being lost. Because they can carry so much, it’s easy for them to become overloaded for your child’s size and muscle strength. Make sure your little one isn’t carrying too big a load and knows how to properly lift and strap on his or her backpack.

Story source: http://orthoinfo.aaos.org/topic.cfm?topic=A00043

 

Your Child

Asbestos Found in Children’s Crayons and Toys

2:00

Coloring with crayons has been an American tradition since the late 1800s.  Since that time, the wax crayon has been instrumental in teaching children how to draw and imagine the world in a rainbow of colors.

Although the words “non-toxic” appear on crayon boxes designated for children’s use, a new report from the Environmental Working Group (EWG) Action Fund says that asbestos fibers have been found in crayons and other toys sold in the United States.

The fibers were found in four brands of crayons and two children’s crime-scene toy fingerprint kits.

The contaminated crayons included Nickelodeon's Teenage Mutant Ninja Turtles crayons, Disney's Mickey Mouse Clubhouse Jumbo Crayons and Saban's Power Rangers Super Megaforce Jumbo Crayons and ones by Amscan, according to the new report.

Asbestos was also found in two crime lab toys: EduScience's Deluxe Forensics Lab Kit, and Inside Intelligence's Secret Spy Kit.

The U.S. National Institutes of Health (NIH) notes that asbestos, which is composed of long, thin mineral fibers, once was common in insulation material.

Though tiny and invisible to the naked eye, airborne asbestos fibers are easily inhaled. With time, scarring, inflammation and breathing impairment can occur, as can lung cancer and mesothelioma, a rare cancer of the lining of the lungs and abdomen, according to the NIH.

Asbestos is no longer widely used in manufacturing in the United States. It is banned in nearly all other developed nations, the research group said.

EWG hired an independent company, Scientific Analytical Institute from Greensboro, N.C., to conduct so-called transmission electron microscopy tests to look for asbestos. This is said to be the most sensitive and accurate method of testing available.

EWG said that a second independent lab reconfirmed the crayons and toys that tested positive.

"Just a couple of fibers can lodge in your lungs and be there forever," said Sonya Lunder, a senior analyst with the Washington, D.C. based group. "And there's very clear evidence that asbestos leads to two forms of cancer, and thousands and thousands of Americans have been killed by fiber exposure."

Former U.S. Assistant Surgeon General Richard Lemen welcomed the report.

"These are important findings, because asbestos is being placed in children's products," said Lemen, now an adjunct professor with Emory University's Rollins School of Public Health in Atlanta.

"Even if the absolute risk is relatively low, children are more vulnerable to toxic material and carcinogens," he said. "And because they are so young they have a longer latency in which to develop these diseases, which are known to be diseases that develop over time."

The crayons were purchased between February and May of this year at two national chains -- Party City and Dollar Tree -- in a suburban county near San Francisco. The group said it ordered the two crime scene toys through Amazon.com and Toys"R"Us.com.

For analysis, 28 brands of crayons were tested and 21 toy fingerprint kits. All the products that tested positive were made in China.

A spokeswoman for Toys "R" Us, which distributes the EduScience Deluxe Forensics Lab Kit, responded to the report, saying customer safety is the company's highest priority.

"We require that every product we carry meets or exceeds all applicable state and federal laws, industry standards, codes and requirements. At this time, we are reviewing the referenced report, along with supplier test reports, to ensure full compliance to our strict safety standards," Kathleen Waugh, vice president of corporate communications, said in a statement.

The tests discovered the highest concentration of asbestos was found in the toy crime-scene fingerprint kits.

If your child is one of the millions that play with crayons or the crime lab kits, be sure to check the brand to make sure they are not one of the contaminated products or kits that tested positive for asbestos.

Source: Alan Mozes, http://consumer.healthday.com/cancer-information-5/lung-cancer-news-100/asbestos-found-in-kids-crayons-toy-crime-kits-701117.html

 

 

 

 

Your Child

Should More Kids Have Their Tonsils Removed?

2:00

Two new medical reviews suggest that more kids could benefit from having their tonsils removed if tonsillectomy guidelines were less stringent.

Currently, surgery qualifications require that a child must have many recurring throat infections within a short span of time or severe sleep disturbances, said Dr. Sivakumar Chinnadurai, a co-author of the reviews.

An evaluation of current medical evidence suggests more kids would receive significant short-term improvement in their daily life if the guidelines were relaxed, said Chinnadurai, a pediatric otolaryngologist with Vanderbilt University Medical Center in Nashville.

Chinnadural and his team found that children, who underwent a tonsillectomy even when they did not meet the guidelines, experienced nearly half as many sore throats. They also missed fewer days of school and were less likely to need extra medical care.

The benefits seemed to apply only to the first couple of years following surgery. By the third year, there was no clear benefit in terms of the number of sore throats, said Chinnadural. The benefits after the first couple of years following surgery, however, were impressive.

"The decision about whether those children should have tonsillectomy for that temporary benefit is really tied to what those children need or what they're suffering with," Chinnadurai said. Kids who miss a lot of school or need frequent trips to the doctor due to sore throats could benefit from the surgery, he said.

There's an even clearer benefit for kids whose sleep is disturbed due to inflamed tonsils, Chinnadurai said.

"In a child with a diagnosis of sleep apnea, we can see a benefit in sleep-related quality of life," he said. The kids get better sleep, and thus exhibit better everyday behavior and pay more attention in school.

Better sleep in children with sleep apnea can improve many aspects of their daily

lives.

Guidelines say a tonsillectomy to treat throat infections is justified if a child had seven or more sore throats during the previous year; five or more sore throats two years running, or three or more sore throats for three years in a row, according to the background notes.

The researchers decided to review whether the throat infection guidelines are too stringent, ruling out patients who potentially could benefit but don't meet the high threshold of recurring infections, Chinnadurai said.

There aren't strong guidelines regarding the use of tonsillectomy to treat sleep disorders, so the doctors reviewed the evidence to see whether the surgery outperformed so-called watchful waiting -- monitoring the situation.

The study results showed "there may be new evidence that supports expanding the criteria and opening up the procedure to more individuals," said Dr. Alyssa Hackett, an otolaryngologist with the Icahn School of Medicine at Mount Sinai in New York City.

"In the right child with the right indications, these are really wonderful procedures that can be life-changing for both the child and the family," said Hackett, who wasn't involved with the new research.

Although the findings were positive, Chinnadural and Hackett both warned against automatically choosing a tonsillectomy when a child has a sore throat.

"Though a tonsillectomy is low-risk, it is not risk-free, and those risks need to be weighed against the benefits for each individual child," Chinnadurai said.

"We're talking about a child who has significant sleep-related issues," Hackett said. "We don't want people to say my child snores, they need to have their tonsils out. That's not what this study says at all."

Parents should discuss the risks and benefits of a tonsillectomy with their pediatrician if they are concerned about the amount of sore throats their child has, or if sleep apnea is diagnosed.

The two reports were published online in the journal Pediatrics.

Story source: Dennis Thompson, https://consumer.healthday.com/kids-health-information-23/tonsillitis-news-669/should-more-kids-have-their-tonsils-out-718738.html

Your Child

Are First Born Children Smarter?

1:30

Who’s the smartest among your siblings? If you’re the first born, then you are, according to a new study.

Researchers from the University of Edinburgh, the Analysis Group and the University of Sydney found that children who were born first typically scored higher on IQ tests than their younger siblings.

First-born children may have better thinking skills than their siblings because they received more mental stimulation during their early stages of development, researchers said.

For the study, researchers used data from the U.S. Children of the National Longitudinal Survey of Youth on nearly 5,000 children who were monitored from pre-birth to age 14. Every two years, the children in the survey were assessed on a variety of categories, including reading, vocabulary assessment and matching letters.

The research found that firstborn children typically perform better than their siblings as early as age 1, which could be due to how parents treat subsequent children. According to the study, parents were less likely to partake in mentally stimulating activities with their younger children, meaning they may not have developed the same thinking skills as the older sibling.

The results from this study are similar to other studies that have looked at whether birth order plays a role in IQ level and personality traits.

While the study has similar findings as other studies along this line, siblings may beg to differ as to who is actually the smartest in the family.

The study was published in the Journal of Human Resources.

Story source: Mary Bowerman, http://www.usatoday.com/story/news/nation-now/2017/02/13/study-first-born-children-smarter-than-their-siblings/97846312/

Your Child

Nicotine Poisoning in Young Children Skyrockets 1,500% in 3 years

2:00

In the last 3 years, there has been an astonishing increase in calls to poison control centers from caregivers and parents of children who have or might have been exposed to liquid nicotine.

From 2012 -2014, accidental exposures to e-cigarettes by children under the age of 6 increased by about 1,500 % according to researchers analyzing nicotine and tobacco product poison control calls.

Children with accidental exposures to e-cigarette liquids were more than five times more likely to be admitted to a medical facility than those exposed to traditional cigarettes and more than twice as likely to have severe medical outcomes, wrote researcher Gary A. Smith, MD, of the Nationwide Children's Hospital Center for Injury Research and Policy in Columbus, Ohio, and colleagues. Their study was published online in the journal Pediatrics.

"These are not trivial exposures. There were comas, seizures, and even one death in the 40-month period we studied, and these exposures were predictable and preventable," Smith told MedPage Today. "E-cigarettes and vaping liquids are products that should never have entered the market without adequate consideration of the harms they could cause to young children."

Not only are children becoming seriously ill because of accidental nicotine poisoning, but children have died from it.

"One death to a 1-year-old child occurred associated with nicotine liquid accessed from an open refill container," the researchers wrote. "Children exposed to e-cigarettes or other tobacco products had higher odds of having a severe outcome than children exposed to cigarettes."

Nicotine is a toxic substance that can cause convulsions, coma, vomiting, irregular heart rhythms, weakness and even death. Before the availability of e-cigarettes and liquid nicotine, acute nicotine poisoning usually occurred in young children who accidentally chewed on nicotine gum or patches.

The study comes right after two new initiatives have been established to put the brakes on nicotine poisoning in children.

The Child Nicotine Poisoning Prevention Act will take effect this summer and will require child-resistant packaging on liquid nicotine containers.

Also, the Food and Drug Administration released long-awaited rules last week, requiring e-cigarette companies to undergo federal review to stay on the market and add health warnings to their products. The new regulations, which take effect in August, also ban the sale of e-cigarettes to anyone under the age of 18.

Many health officials are upset that the FDA has taken so long to address the dangers of nicotine poisoning in young children.

"Liquid nicotine is another example of a highly toxic product that was put into the marketplace without consideration for safety of children," Smith said. "It's as if we're treating our children as canaries in the coal mine. We wait until there's a dramatic event and then do something."

Smith also acknowledged that many parents might not know just how dangerous these products can be for children. "Even a relatively small dose, which may not cause many effects in adults, can cause major effects in kids."

If you suspect that your child has ingested nicotine, experts recommend that you NOT induce vomiting, but call poison control at 800-222-1222 or that you call 9-1-1.

Story sources: Naseem S. Miller, http://www.orlandosentinel.com/health/os-e-cig-kids-poisoning-rising-20160509-story.html

Salynn Boyles, http://www.medpagetoday.com/Pediatrics/Parenting/57795

Your Child

More Kids Suffering ACL Injuries

2:00

Kids involved in sports like soccer, basketball and football are increasing their odds of damaging their knees, according to a new study.

A common knee injury — an anterior cruciate ligament (ACL) tear — has steadily increased among 6- to 18-year-olds in the United States, rising more than 2 percent a year over the last two decades, researchers report.

These injuries peak in high school, said lead researcher Dr. Nicholas Beck, an orthopedic surgery resident at the University of Minnesota. Girls have a higher rate of ACL injuries, Beck added.

Sports like soccer and basketball often require the child to pivot or cut back and forth, putting stress on their ACL and risking a tear.  Contact sports like football can further increase the risk. But ACL tears can occur in tennis and volleyball, too.

The study didn’t look at why the injuries are on the rise, but co-author, Dr. Marc Tompkins, an assistant professor of orthopedic surgery at the University of Minnesota, has a theory.

“One potential cause is the year-round sports specialization that is occurring in kids at an earlier age,” Tompkins said.

Instead of playing a variety of sports and using different muscle groups, many kids are focusing on just one sport creating muscle fatigue and an increase for injury, Tompkins explained.

“Another potential cause is that children as athletes play with more intensity and force than 20 years ago, which may put the body at increased risk of injury,” he added.

The numbers of girls experiencing ACL tears are rising because their sports participation numbers are up.

Beck hopes this study will increase awareness of ACL tears in young athletes and promote interest in prevention programs or developing athletic participation guidelines.

The anterior cruciate ligament sits in the center of the front of the knee. It’s one of the ligaments that holds the knee bones together. When it tears, the ligament splits into two, causing knee instability, according to the American Academy of Orthopaedic Surgeons.

“ACL injuries are serious in the short term because they generally require six months’ to a year’s worth of hard recovery work before going back to sports. And even then it often takes longer to get back to pre-injury function,” Tompkins said.

“ACL injuries are serious in the long term, too, because we know that even if they recover well with or without surgery, the risk of developing arthritis in the injured knee is higher than before the injury,” he added.

Some sports medicine specialist say there are ways to reduce injuries among young athletes, by having coaches teach good running techniques that promote improved function and agility.

Children participating in sports can also benefit from flexibility and stretching programs.

The researchers found that girls of all ages experienced a significant increase in the incidence of ACL tears over 20 years. In boys, however, only those aged 15 to 16 showed such an increase.

The report was published online journal Pediatrics.

Story source: Steven Reinberg, http://www.cbsnews.com/news/acl-tears-on-the-rise-among-kids-especially-girls/

Your Child

CDC Warning: Dangerous Pool Parasite

2:00

With temperatures in the high 80s and 90s, lots of families are cooling down with a swim in the pool. It’s pretty much become a summer tradition over the decades and can be a great way to have fun, exercise and beat the heat.

However, there is a parasite outbreak that parents should know about before allowing their children to swim in public, private or even their own pool.

The parasite is Cryptosporidium and it can cause gastrointestinal symptoms such as nausea, watery diarrhea, vomiting, fever and stomach cramps. You can become infected with cryptosporidium by touching anything that has come in contact with contaminated feces.

The parasite is encased in a tough shell and is not easily removed by typical pool treatments like chlorine or bromine. It can survive for several days after a pool treatment, whereas e-coli is typically eliminated within minutes.

The Centers for Disease Control and Prevention (CDC) recently issued a warning about the dangers of Cryptosporidium in pools and hot tubs.

CDC's Healthy Swimming Program chief Michele Hlavsa said that the outbreaks commonly affect children.

"With these outbreaks, we see they disproportionately affect young children," Hlavasa said, "They're the ones who can go to a pool and young children tend to carry lots of germs."

The parasite can be cleared from the body in about two to three weeks, Hlavasa said, but in a person with a weakened immune system the condition may become chronic or even fatal.

Pool owners can help reduce the risk to their family and guests by insisting people shower before diving into the water, the CDC stated. This practice could assist in preventing the microorganism from contaminating hot tubs or pools. It is also a good idea for anyone experiencing diarrhea to stay out of pools, the national public health agency recommended. Parents of young children are advised to change diapers well away from pools, in order to prevent contamination of the water by human waste.

For families visiting public pools, the CDC recommends that parents look to see their pool's most recent inspection was posted through their local health department or even look into buying their own chlorine tests that can be used to test if the water is properly treated.

The CDC also provides several sets of tips to help prevent water-borne illnesses:

Keep the pee, poop, sweat, and germs out of the water!

•       Stay out of the water if you have diarrhea.

•       Shower before you get in the water.

•       Don't pee or poop in the water.

•       Don't swallow the water.

Every hour—everyone out!

•       Take kids on bathroom breaks.

•       Check diapers, and change them in a bathroom or diaper-changing area—not poolside—to keep germs away from the pool.

•       Reapply sunscreen.

•       Drink plenty of fluids.

Check the free chlorine level and pH before getting into the water.

•       Pools: Proper free chlorine level (1–3 mg/L or parts per million [ppm]) and pH (7.2–7.8) levels maximize germ-killing power.

•       Hot tubs/spas: Proper disinfectant level (chlorine [2–4 parts per million or ppm] or bromine [4–6 ppm]) and pH (7.2–7.8) maximize germ-killing power.

•       Most superstores, hardware stores, and pool-supply stores sell pool test strips.

Enjoying the benefits of swimming is something that families everywhere will be taking advantage of this summer. Remember, we share the water—and the germs in it—with everyone. Take these few steps ahead of time to help make sure summer pool fun doesn’t turn into a summer illness.

Sources: http://www.cdc.gov/features/healthyswimming/

Gillian Mohney, http://abcnews.go.com/Health/cdc-warns-pool-parasite-summer/story?id=32060444

 

 

 

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