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Simkin, B. (1997).
Understanding medications and medical interventions. In D. Chen (Ed.).
Effective practices in early intervention. Infants whose multiple disabilities include visual
impairment and hearing loss (pp.177-192). Northridge, CA: California State University,
Northridge, Department of Special Education (ERIC Document Reproduction Service No. ED
Understanding Medications & Medical Interventions
by Beverly Simkin RN,PHN
The birth of a child who has a disability is a difficult and stressful time for a family. It is a time when parents must grieve the loss of the "perfect" baby that they had anticipated and deal with the medical and emotional complexities of the situation (Batshaw, 1991).
When the infant is finally discharged home from the hospital, the parents are generally overwhelmed with the "special care" that their baby needs. Besides feeding and infant care, medications, treatments and special equipment become part of the daily routine. Parents must learn to cope with their dependency on medical and paraprofessional personnel for advice and intervention.
The following information covers issues frequently encountered by Early Interventionists (EI) during home visits and/or center based sessions by offering clarification of common medical concerns and interventions. It is a collection of practical information that can be shared with families and team members to enhance the understanding of health related issues.
It may be necessary for an infant to receive medication for an injury, illness or medical condition. Medication must be given as prescribed by the infants doctor. The EI and the parent(s) should observe the infants response to the medicine once it is given. It is important to note if the medicine is effective. Is it doing what it is suppose to do? The infants doctor should be contacted immediately if the infant shows any side effects or adverse reactions. Parents should be reminded to give all the medication that is prescribed for their infant. Even as the infants condition begins to improve, some therapies require a full treatment plan before lasting results can be achieved. Never change the dose and/or frequency of any medication an infant is receiving without consulting a physician.
Medication Dos & Donts
1. Keep all medication out of reach of children.
2. Give medicine at the times prescribed by the doctor.
3. Store medication as indicated by the pharmacist and/or drug company.
4. Keep an extra bottle of medicine in emergency supplies. If it is a prescription, check the expiration date periodically.
5. Measure liquid medicine in a measuring spoon or medicine syringe for accuracy. Do not use tableware.
6. Ask your pharmacist for child protective caps on all bottles of medicine.
1. Dont mix the medicine in a full bottle of milk or juice. (The infant may not finish the whole bottle and will not get the required dosage).
2. Dont mix medicine with a favorite food. (The child will associate medicine with it and will stop eating it).
3. Dont give medicine that is expired, as it will have decreased effectiveness or no effect on the problem. Do check the expiration date!
4. Dont give medication that is prescribed to someone else. This is dangerous and foolish.
Possible Questions/Concerns for the Family
1. What are the side effects of the medicine that my baby is taking?
Generally, most medications are taken without any problems. Occasionally, a drug may cause a rash or upset stomach which would be considered an adverse side effect. It is important to read the medication insert that is provided with the medicine from the pharmacy or pharmacist. It would be appropriate to call the pharmacist or physician with any questions or concerns about the drug. Many pharmacies have a "hot line" for medication questions at their disposal.
2. Can I give his/her medication with food?
All dispensed medication must be labeled with easy-to-read instruction including: patients name, dose, method administration, frequency of administration, storage requirements and any special instructions. Medications such as analgesics and antibiotics need to be taken with food since they can upset the stomach, while other medications absorb better if the stomach is empty. It is very important to read the "medicine bottle" instructions prior to administration of medicine to infants and children. Medication instructions can also be requested in Spanish for Spanish speaking families. The request for Spanish instructions should be made at the time the prescription is dropped off to be filled. Requests can also be made for the medication to be placed in two bottles for an emergency pack or supplies for child care.
3. What do I do if I spill or lose the medicine for my baby?
Just call the pharmacy where the prescription was filled and explain the circumstances. Generally, extra medicine will be provided (for an additional charge) so that the course of therapy can be completed.
Many exams and procedures require the infant to be completely still, so that the procedure can be completed quickly and safely. Since all children have difficulties remaining immobile, it is necessary to sedate them.
Sedation of infants and children can be achieved by giving medication orally or rectally, by injection or intravenous therapy. Medication taken by mouth or rectally needs time to be absorbed through the intestinal tract before it reaches the blood stream and can be effective. This process can take up to one hour before the infant falls asleep. Medication given by injection or intravenous therapy (IV) acts much faster since it is administered directly into the muscle or blood stream. Medication given this way will usually take effect in 10-20 minutes (Physicians Desk Reference,1995).
The type of medication that an infant will receive depends on the level of sedation required for the procedure, the age of the child, the setting or location where the procedure will take place and the physicians preference (Lovejoy,1987). Some procedures require the infant to be completely immobile while other procedures require him/her to be sleepy or tired. Depending on the level of sedation, the infant may need to be monitored until awake and alert before going home.
General anesthesia is the strongest form of sedation. This type of sedation is often necessary to reduce the risks of injury during a procedure or medical exam (Lovejoy, 1987). General anesthesia provides complete sedation in a controlled setting at which time the infant is monitored very closely. It is available only in an operating room setting where it is administered by a anesthesiologist or nurse anaethetist. It is given through a mask over the face and is often preceded by an injection to make the infant tired or sleepy.
When an infant requires general anesthesia, the anesthesiologist or nurse anaethetist will meet with the parents in advance to discuss the scheduled procedure.
He/she will ask questions about the infant that may have been asked before and will
want to know if the infant has any allergies to foods or medications. The parent(s) may
be asked to sign a consent for the general anesthesia separate from the procedural consent, since the doctor/nurse practitioner who administers the anesthesia is different from the one doing the procedure.
Possible Questions/Concerns for the Family
1. How long will it take before my baby wakes up? (This is an important question for the parent(s) to ask the doctor in charge.)
The level of sedation required for the procedure, the drug used and the babys ability to excrete that drug from his/her body will determine how long it will take for the baby to wake up. Regardless of the type of sedation received, it usually takes a day for a baby to be back to his/her usual level of activity.
2. Can the baby still eat if he/she has to be sedated?
In most cases when food must be restricted prior to medication or procedure, the infant is scheduled for the first morning appointment. This way the infant does not have to wait very long without eating (since he/she usually does not need a bottle at night). If the infant is scheduled for a surgical procedure where general anesthesia is necessary he/she must have nothing to eat at least 6-8 hours prior to this event. Sometimes the combination of food and the anesthesia may cause the infant to throw-up, so it is best that the stomach remain empty to avoid aspiration of the stomach contents should the baby vomit.
After the procedure is completed the baby should not be fed until he/she is completely awake to avoid complications of aspiration of food. A sleepy baby will have trouble swallowing and may choke and gag on a bottle of milk or juice.
3. Can my baby still be sedated and have the procedure if he/she has a cold?
It is up to the doctor to determine if the baby is stable enough to undergo the procedure prescribed. It will also depend on the imminent need for the infants health and well being. Many physicians will have the parent(s) follow up with their pediatrician/care provider to determine the infants health status prior to any procedure that requires sedation. If there are still health or medical issues related to the infants status, a phone call to the doctor in charge may help clarify the situation. It is the doctors responsibility (not the early interventionist) to provide information to the parents to alleviate fears. "Informed Consent" is a law that requires physicians to explain in full all aspects of any medical procedure prior to the medical intervention.
Seizures are caused by abnormal and excessive electrical discharge from neurons in the brain. Resulting behaviors may include loss of consciousness and muscle spasms (clonic-tonic) a dazed look, staring, or twitching (Batshaw, 1991; Lovejoy,1989). There are many types of seizures that are a result of numerous medical and/or neurological diagnoses including prematurity, infections, trauma, and hypoxia.
It is important to notice and record events leading up to, during and after a seizure, along with any other information that may be related to the event (e.g. duration, frequency). If you notice an episode during an intervention session you should collect these data to share with parents so they may follow up with their infants doctor.
When a seizure occurs remain calm and keep the infant safe from harm. You may need to position the infant on his/her side to prevent aspiration of secretions. Do not restrain the babys body movements and call for help if you feel you need it!.
Long term management is directed at prevention of seizures and promotion of normal development of the infant/child.
Febrile seizures occur in up to five percent of children during childhood (Chow,1979). Generally these seizures are associated with a rapid rise in an infants temperature due to illness or immunization. Febrile seizures are characterized as lasting less than five minutes, having a single occurrence and causing no changes in brain wave patterns (i.e. EEG). Parents should notify their physician immediately to determine appropriate follow up care. Children who show recurrent signs of febrile seizures may be given a daily prophylactic dose of an anti-convulsant to prevent further episodes.
Do's and Don'ts of Seizure Precautions
1. Do remove hard and dangerous objects from the area.
2. Do lower the child to the ground, if possible.
3. Do attempt to lay the child on his or her side with the hips elevated and the head turned to the side.
1. Do not place any object between the childs teeth.
2. Do not restrain the child in any way.
3. Do not pour liquids into the childs mouth; he or she may inhale the liquid and begin to choke.
4. Do not attempt to ensure that the child does not swallow his/her tongue. It is impossible for that to happen.
An EEG is sometimes indicated to provide a more complex evaluation of the
nervous system, to rule out or confirm a seizure disorder and to provide baseline information for future use. This procedure is performed by attaching very small electrodes to the scalp of the infant with tape. The electrodes are prepared by applying a white paste to the tips prior to placing them on the scalp. The paste improves the conduction of the electrical impulses that travel through the electrodes and up the wires. These wires are attached to a computer that record the brains electrical impulse patterns (Batshaw, 1991).
The infant must be completely still and is sedated to achieve a sleep state for best results. Movement by the infant will disturb the brains wave patterns and furnish
unclear results. The exam takes approximately one hour once the infant is asleep and is repeated in intervals of six months to a year or as necessary.
Possible Questions/Concerns of the Family
1. Will the seizures go away when my baby takes the medication?
Seizure disorders are generally a chronic, ongoing problem for infants and children who have them. Medication can help reduce the symptoms of the disease but usually does not eliminate it (the disease). Situations that are stressful to the infant may cause a flare up of seizures. Rapid growth spurts may demand frequent changes in medication doses and impact the anti-seizure therapy.
2. My baby is always sleepy. Can I decrease the medication?
Sleepiness may be an indication that the infant may be receiving more medication than he/she requires. It is important to notify the physician and discuss the infants behavior if he/she is unusually sleepy or lethargic. A physician should only determine changes in medication. Guidelines on how to make a simple adjustment in the medication (if the situation permits) are usually given by the physician at the time of medical intervention.
3. If my doctor tells me over the phone to increase/decrease medications, is it safe?
Physicians are trained to give advice and orders over the phone. It is a very common practice for physicians to provide information concerning changes in medications and/or dosages. It is vital to observe the infants behaviors after a medication alteration and report to the doctor any changes (positive or negative) that occur.
Related Problems or Illness
Otitis Externa (Swimmers Ear)
This is a painful infection of the external auditory canal. It causes pain upon movement of the ear, swelling and possible discharge. Ear drops are generally prescribed to relieve the pain and cure the infection (Lovejoy, 1987; Mitchell & Eiger, 1994).
Serious Otitis Media ( Fluid in the Middle Ear)
This is a condition in which there is an accumulation of fluid in the middle ear that may be caused by allergy, colds, ear infections or changes in altitudes or pressure. It may continue for weeks or months following and ear infection and may cause a sensation of fullness in the ear. A decrease in functional hearing ability may also occur. Fluid in the middle ear decreases the motility of the ear drum and is detected during visual inspection of the drum or tympanometry (Lovejoy, 1987; Mitchell & Eiger, 1994).
Suppurative Otitis Media (Middle Ear Infection)
This is a bacterial infection of the middle ear that is very common in infants and children. It causes severe pain and needs prompt attention. Due to the position of the infant/childs eustachian tube, (which is shorter and more horizontal than an adults) leads to the higher incidence of this problem with this age group. The infant may show signs of nasal congestion, ear pulling, irritability and/or fever. Oral antibiotics are generally prescribed for 7-10 days along with a follow-up ear check at the end of the drug therapy (Lovejoy, 1987; Mitchell & Eiger, 1994).
Many infants and children have an occasional ear ache or ear infection that is cleared up with drug therapy. They usually do not have significant, long lasting effects on the infant/childs hearing. However, middle ear fluid may linger for many weeks following an ear infection and needs to be monitored by the physician.
Chronic Otitis Media is a condition in which infants and children are plagued continuously with recurrent middle ear infections following repeated courses of antibiotic treatment. Infants and children who have six or more ear infections a year are considered to have this problem. This condition can significantly impact the infant/childs hearing and language acquisition and the patient should be referred to an Ear-Nose & Throat (ENT) Specialist for consultation and evaluation. Early identification of a hearing loss through regular hearing screenings is extremely important. It is also recommended that hearing testing be done prior to six months of age for all children who are premature, developmentally and/or multiply disabled as they are at a higher risk for a hearing loss (Batshaw, 1991; Lovejoy, 1987).
If antibiotics and decongestants are ineffective for chronic or serious Otitis Media,the doctor may recommend a procedure that is called myrigotomy with vent tubes to combat the problem. In this procedure, a very small hole is placed in the ear drum and the middle ear fluid is drained. Next a very small vent tube is placed into the ear canal and pushed down the ear canal until it reaches the ear drum. The vent tube is then nudged into the ear drum where it is left to stay. The ear drum eventually adheres to the vent tubes to secure them in place. This allows pressure on both sides of the ear drum to equalize and allows accumulated fluid to drain as necessary. This is a very delicate procedure and requires the infant to be completely immobile, therefore, general anesthesia is required. The procedure takes approximately fifteen minutes once the infant is surgically prepared (Lovejoy, 1987; Spock & Rothenberg 1992).
Following the placement of "tubes," it is important for the parent(s) to adhere to the directions for the care and the maintenance of the vent tubes. There has been controversy on the care of vent tubes, keeping canals dry vs. no restrictions (Lovejoy,1987; Chow,1979). It is important to ask the parent what they have been told to do by the physician and follow the parents instructions.
Possible Questions/Concerns for the Family
1. Why does my baby have to take medicine all the time?
Antibiotics and decongestants are the first line of treatment for ear infections. They are relatively safe and generally effective for this problem. Some infants may need many courses of different drug combinations until the condition is cleared and will then be placed on prophylaxis antibiotic therapy to stop a recurrence. Ultimately, some may need surgery and the placement of vent tubes.
2. What effect does ear infections have on my babys ability to hear?
Fluid trapped in the middle ear (infected or not) will cause a conductive hearing loss. This means that the infant will not be hearing certain sounds or words or that they may be distorted and/or unclear. If this condition is ignored, it can severely impact a childs communication and language development. It is important to follow-up on ear exams and hearing tests to determine the effectiveness of medical treatment and hearing ability. If middle ear fluid is a chronic condition, a consultation with an ENT specialist would be important.
Some infants will have difficulties eating enough food to sustain normal growth due to neurological and/or oral tactile defensiveness (does not like things or food textures in or near the mouth or face) problems (Batshaw, 1991). As a temporary measure, a thin tube is passed through the nasal opening down to the stomach which is call a naso (nose)- gastric(stomach) tube. When a child has significant difficulty getting enough nutrition by mouth, a gastrointestinal tube (G tube) is placed through the abdominal wall directly into the stomach (Batshaw, 1991). Liquids as well as semi-solid supplements can be given through either of these tubes by gravity (also known as gavage feeding). The G tube can be for supplemental feedings only or may be the avenue for total nutritional support. A G tube is not a treatment that should restrict activity or positioning of an infant. Most infants learn to discriminate which positions are most comfortable and generally let their caregivers know how to position them.
You may encounter an infant that uses a feeding/Kangaroo pump. This is a machine that gives the nutritional supplement at regular amounts and over a predetermined period of time, at regular times during the day and night or only at night. It is up to the infants doctor to determine the rate and the amount of supplement to be given. This amount is based on a formula growth rate in relation to caloric intake.
Possible Questions/Concerns for the Family
1. How long will my baby be on a G tube?
The length of time an infant will need a G tube depends on his/her nutritional needs and ability to take food in by mouth. It will be up to the physician and/or medical team to determine the duration in which a G tube will stay in place.
2. How can I bathe my baby?
Once the G tube has been in place and the doctor allows bathing, the infant can
be bathed in the regular manner. In general, infants prefer tub baths but the shower is fine if that is the infants normal routine. Remember to dry well the area around the tube as it can become irritated if moisture is allowed to accumulate there. If the area around the tube should become reddened, irritated or "weepy" it is important to contact the physician to determine the appropriate care.
3. How will he/she learn to eat?
When a child has been using a G tube for a significant amount of time for his nutritional needs, he/she often becomes used to eating through the tube and no longer has the need or desire to eat by mouth. Also when a child is a fed by a G tube his/her feedings are usually scheduled and the child does not have the opportunity to experience hunger. Another problem that may be encountered is the fact that an infant may not have the oral motor skills necessary for sucking or eating or may be oral tactile defensive (does not like things or food textures in or near the mouth or face).
Once the child is out of danger for weight loss and his/her nutritional status is no longer a threat to his/her well being, the therapeutic focus can turn to getting the child to eat by mouth again. This can be a long and difficult process to teach a child to eat again by mouth and takes the combined efforts of the medical team, intervention team and family for this process to be successful.
It is important to remember to encourage infants to place approved appropriate infant items in there mouth (i.e. pacifier, wash cloth, toy) whenever possible, especially if they are receiving feedings through a G tube. Also, if approved by the physician, give the infant small amounts of food or formula by mouth prior to or during a G tube feeding to associate feeding with food in the mouth and not just through the tube.
4. What happens if the tube falls out?
Before your infant is discharged from the hospital you will be instructed on the care and maintenance of the G tube. Instructions include how to reinsert the G tube if it should fall out. It is important to insert the new tube as quickly as possible so the opening to the stomach will not close. Go straight to your physician or medical center for immediate follow-up care.
Respiratory tract infections are the most common cause of illness in infants and children. They include symptoms of cough, respiratory difficulties, rhinorrhea (runny nose) and sore throat. The causative agent is generally a virus and most infections are treated symptomatically with fluids, humidification and medication (Brazelton, 1983; Leach, 1995, Lovejoy 1987).
It is important for an early interventionist to use "good" judgment and universal precautions when confronted with an infant who has an upper respiratory infection (URI). If the infant has an active URI and is producing lots of discharge, it is probably a good idea to postpone your visit until another time. Since it is hard to determine whether an infant is "coming down with something or not," it is important to ALWAYS follow universal precautions with every infant or child that you visit.
1. Wash your hands before and after each visit.
2. Use a disinfectant solution to wash all toys that the infant has touched or mouthed after each visit.
3. If you wipe the infants nose during a visit, use plenty of tissues and wash your hands right away.
4. Do not visit an infants home if you have a cold! Many of the infants that you serve are medically fragile and are more susceptible to infection.
1. Wash your hands before the program begins and when your hands become "dirty" from activities or infants secretions.
2. If you change a childs diaper use good hand washing technique and protective gloves. Dispose of the diaper properly as your program has indicated.
3. Wash all toys that the infant has touched or mouthed with a disinfectant solution when an activity is completed before other children use them.
4. If you wipe the infants nose, use plenty of tissues and wash your hands right away.
5. If you have a cold it may be best to stay home until you are feeling better. If you must work, refrain from interaction with the children since you could be contagious. Many of the infants that you serve are medically fragile and are more susceptible to infection.
Source: Lovejoy, F (1987)
Severe acute and chronic respiratory conditions (eg. asthma) often require special equipment for their treatment. They may require oxygen, suction equipment, or respiratory treatment machines (Batshaw,1991). It is necessary to know what precautions (if any) are required.
Oxygen- Comes in green tanks of varying sizes or in a liquid form sometimes called a "Lindy Walker". It should never be used in the presence of an open flame such as a lit cigarette, stove or fireplace. It is administered through nasal prongs for continuous use or by mask for temporary therapy. Some children may outgrow the need for even intermittent therapy and eventually only require oxygen during an illness.
Suction Equipment - It is a portable unit that can be plugged into the wall or run on battery. A supply of suction catheters (long thin tubing) are used and can be passed through the nose, mouth or tracheostomy down to the lungs, depending on the needs of the infant. Parent(s) are instructed on operation and care of the equipment for use in the home.
Respiratory Treatment Machines- These are machines that administer medication directly into the lungs under positive pressure. Respiratory medicine is placed in a chamber that is attached to the tubing that is connected to both the machine and PulmonAid the infants mask. When the machine is turned on, air is pushed through the tubing and medicine chamber forcing the medicine out (like a mist) into the infants mask. The oxygen mask is then placed over the face of the infant so he/she can inhale the medicine during the natural rhythm of breathing. The mask remains in place until the medicine in the drug chamber is completely gone. The benefit to this mode of treatment is that the medicine can be placed directly in the area where it is needed. When respiratory medicine is given in this way, the medicine has virtually no adverse side effects.
Possible Questions/Concerns for the Family
1. How will I be able to provide all of these therapies for my baby? Im not a nurse!
Before an infant is discharged from the hospital instructions on required infant care are always given. The hospital staff encourage parents and family members to practice the infants care before leaving the hospital while so caregivers will feel comfortable and confident in their ability to care for the baby.
2. How can my 3 year old attend the center-based program if he needs oxygen, suctioning or respiratory therapy?
It will be up to the medical team, intervention team and family to determine the stability of the toddler to attend programs outside the home. Although all equipment is portable, it may be too overwhelming to travel with an infant who is medically fragile. Home programming may continue or alternative (often creative) methods of transportation can be developed to get the infant to and from the agency.
3. Should my toddler attend the center-based program if he seems to get sick?
Many toddlers, when exposed to a center-based preschool environment, tend to get sick more often. Illness occurs when the toddler is exposed to new sets of "germs" from the other children. Eventually the toddler builds up a resistance to these "germs" and seems healthier and will become sick less often. In certain circumstances a physician may recommend a toddler to stay at home during specific times of the year when illness is more frequent or recommend further immunizations.
Tips for Parents
1. Obtain copies of all medical records for each child.
2. Place in a binder and organize according to medical specialties (i.e. pediatrics general care, orthopedist, ENT).
3. Have a list of childs physicians and their phone numbers close to the phone.
4. Have a list of current medications (including amount and the reason for usage) close at hand. Make sure to revise the list regularly.
5. Have a list of emergency contacts and procedures by the phone.
6. Make a phone list of all individuals and professionals (including names addresses, phone numbers, and what they do) and place it in your binder.7. Keep track of phone calls by keeping a phone log so you can remember who you called, when you called and for what purpose you called them.
Emergency Telephone Numbers
Poison Control Center
Adverse side effects - unfavorable condition(s) that may occur with use of medications or treatments.
Analgesic - medicine given for pain.
Antibiotic - medicine given for bacterial infections.
Anticonvulsant - medicine given to control seizures.
Antihistamine - medicine given to reduce symptoms of allergy and allergic reactions.
Antipyretic - medicine given to reduce fever.
Aspiration - act of breathing into the lungs.
Baseline - a basis serving as a measurement of comparative studies/tests.
Congestion - nasal "stuffiness" or chest congestion related to a cough.
Decongestant - medicine given to relieve congestion in the nose and chest.
Disability - physical, neurological or genetic disorder that prevents or restricts typical development.
Dosage - amount of medicine to be given.
Excrete - discharge waste material from blood, tissue or organs.
Expiration date - printed on the medication label to indicate when the medicine is no longer "good" to use.
Humidification - adding extra moisture to the air through warm or cold mist.
Hypoxia - lack of oxygen.
Immobile - unmoving.
Injection - shot.
Intermittent - occurring at different times (may or may not be scheduled).
Intravenous therapy - medicine, fluid and/or nutritional supplements given through a thin plastic tubing directly into the vein.
Loading dose - the initial dose of a drug, usually larger than the routine dose.
Monitored - watched or supervised carefully by an individual who is appropriately qualified.
Neurological - related to the brain.
Neurons - brain cells.
Ophthalmic - related to the eye.
Orally- by mouth
Paraprofessional - professionals that are part of the" medical team" to help support
the infant and parents (i.e. Social Workers, Respiratory Therapists, Discharge Planners).
Prematurity - an infant born before term.
Prophylaxsis - medicine or treatment given to reduce the chances of recurrence of
illness or disease.
Rectally - relating to the rectum.
Recurrence - happens again.
Respiratory - related to the lungs.
Route of administration - how the medicine is given (i.e. orally, rectally).
Tracheotomy - a surgical opening in the trachea made from the neck to provide an open airway.
Tympanometry - exam to measure movement of the ear drum.
Universal precautions - using precautions to stop the spread of germs from one individual to another.
Visualization - to make visible.
Batshaw, M. (1991). Your child has a disability. Boston, MA: Little, Brown and Company.
Brazelton, B. (1983). Infants and mothers. New York: Bantam Doubleday Dell Publishing Group Inc.
Chow, M. (1979). Handbook of pediatric primary care. New York : John Wiley and Sons.
Leach, P. (1995). Your baby & child - From birth to age five. New York, Alfred A. Knopf.
Lovejoy, F. (1987). The new child health encyclopedia: the complete guide for parents. New York, New York: Bantam Doubleday Dell Publishing.
Mitchell, M. & Eiger, M. (1994). The pill book guide to childrens medications. New York: Bantam Books.
Physicians Desk Reference, (49th edition). (1995). Oradell, NJ: Medical Economics Data Production Co.
Spock, B. & Rothenberg, M. (1992). Dr. Spocks baby and child care. New York: Pocket Books.