SIDS: Reducing Your Baby’s Risk

SIDS, sudden infant death syndrome, is the leading cause of death among infants, yet there doesn’t seem to be a full-proof way to prevent it. What do we know about SIDS? What are the main ways to try and reduce your baby’s risk? And how can you support a family who experiences this tragedy? Plus, a special interview with Bill Schmid, Founder of HALO® Sleep Systems who lost his daughter to SIDS.

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Parent Savers
SIDS: Reducing Your Baby's Risk

Please be advised, this transcription was performed by a company independent of New Mommy Media, LLC. As such, translation was required which may alter the accuracy of the transcription.

[00:00:00]

[Theme Music]

Jeri Wilson : SIDS is a leading cause of death among infants one month to one year and claims the lives of about 2,500 each year in the United States. It's a parent's worst nightmare. What is SIDS? What are ways to reduce the risk? I'm Jeri Wilson, SIDS Educator, and this is Parent Savers, episode 36.

[Theme Music/Intro]

KC Wilt : Welcome to Parent Savers, broadcasting from the Birth Education Center of San Diego, I am your host, KC Wilt. Parent Savers is all about helping new parents from the baby years to the toddler years. We are so lucky to have amazing experts in our show, so shoot us an e-mail or call our hot-line and we'll get your questions answered. We also have a free app, a free newsletter, you can like us on Facebook, you can send us an e-mail, you can call our hot-line, there are so many ways to be a part of our show. Also, did you miss an episode that's been archived, or you want to keep talking to the expert once the show stops? We have a Parent Savers Club where you can download all the archived episodes, get exclusive content and so much more. So I'm a new parent myself, my son Carson just turned two on Sunday, and I am joined by one new parent and one soon to be new parent. So why don't you introduce yourselves.

Stephanie Saalfeld : Hi, I'm Stephanie Saalfeld, I am 29, I am a dermatologist and I am currently pregnant with my first child, a baby girl.

KC Wilt : How far along are you?

Stephanie Saalfeld : Eight and a half months.

KC Wilt : Congratulations!

Stephanie Saalfeld : Yeah, coming up soon.

Sunny Gault : And I'm Sunny Gault, I have two little boys at home, one is about two and a half, and the other one just turned seven months.

KC Wilt : Oh, gush, it goes by so fast!

Sunny Gault : I still can't believe my son turned two, it was just about yesterday that I gave birth to him.
[Theme Music]

KC Wilt : Joining us on the phone, we have Bill Schmid here, and he's the founder of HALO Innovation, who makes the HALO SleepSacks. Bill has a special relationship to SIDS, explain that to us, Bill.

Bill Schmid : Sure KC, thanks for having me, unfortunately my relationship is one that nobody really wants to have, my wife Cathy and I, we lost our first born child, Haley, to SIDS in 1991. Obviously, everyone can imagine that it was a horrific experience, life changing event. Since then, we have been dedicating our lives and our careers to prevent this from happening to other parents.

KC Wilt : I can't even imagine. We'll be talking about that in the show, about ways parents cope with this, but it's a parent's worst nightmare. What are some ways that you turned this horrible devastation into your company?

Bill Schmid : Well, in 1992 the Back to Sleep campaign started, which was a campaign by the public health and SIDS organizations to convince parents to put their babies to sleep on their back. It was actually one of the most successful Public Health campaigns in history. But on that time we were still coping with our daughter's death and trying to understand it, because it didn't make any sense, she was by all measurements a perfectly healthy little girl, who didn't wake up. But around that time, in that sleep campaign, they were talking about some of the causes and one of them was carbon dioxide rebreathing. When babies get onto their stomachs, with their face down into the mattress, they could breath their own exhaled carbon dioxide, which in certain babies, they wouldn't respond to that normally by moving their head to get more air and eventually suffocate. I had an engineering background, I was working in the engineering field and I came across a study from the Netherlands that talked about the reasons why their SIDS rates were incredibly low, and one of the reasons they believed was because of the use of something they called trample-sack, which was a sleeping bag, a sleep-sack is what we call it. We introduced that product and that concept in North America around 2000-2001. The concept is basically that the blankets that you use in the crib is a simple blanket but it doesn't present any risk for entanglement or the blanket covering the face to cause carbon dioxide rebreathing. And fortunately, ten years later, it seems to be coming to standard in the United States.

Sunny Gault : Definitely, I mean I don't know many parents who don't have a sleeping-sack, it's on all of our closets, pretty much.

KC Wilt : Bill, as a parent who has lost a child to SIDS, what advice to you have for parents out there that might be listening to this show? We are curious about SIDS, obviously, as parents we want to protect our kids as much as possible and do what we can, but what would you say to them?

Bill Schmid : Well, there's a number of things that we may talk about in terms of reducing the risk, and they're really simple things. And if you would to be one of those parents, the odds of SIDS happening are very very small, and I know parents can lose sleep over those, and no matter what you say, they're going to lose sleep. Parents enjoy their babies, as you know, as you were saying, with your two-year old-time goes by so fast, it's a pleasure every day you have with them and you know that if you're taking these precautions that baby's going to be safe.

KC Wilt : Thank you so much Bill Schmid, it was great to have you here talking about your story,

Bill Schmid : Thanks so much for having me and I appreciate you having episodes like this to educate and build awareness because that's the answer.

[Theme Music]

KC Wilt : Today on Parent Savers we have Jeri Wilson, and she is a SIDS Educator here with us. So, Jeri, to start off, what is SIDS and, I've heard also, SUID?

Jeri Wilson : Sudden Unexpected Infant Death.

KC Wilt : What is that, what is the difference between them?

Jeri Wilson : SIDS is the sudden unexpected death of an otherwise healthy infant between one month and one year of age, and it's something that can't be explained after an autopsy or death scene investigation. SUID is something that has many different things under it: you can have a baby pass away from accidental suffocation, infection, and also SIDS. The difficulty in that is that since 1999 the rate of SIDS deaths have gone down, but the rate of SUID deaths have gone up. So we in the SIDS community are wondering if that's one of the accurate statistics with SIDS and if parents are given the SUID diagnosis, how are they being supported and helped?

KC Wilt : I've heard more stories here and there of situations that happened and parents believe that maybe this was the cause and that was the cause, and then they just say it's just ruled off as SIDS, unexplained death. Could that be the SUID?

Jeri Wilson : Alright, so basically the baby dies during their sleep and if the autopsy comes up with nothing, they rule out everything, then it's deemed as SIDS.

KC Wilt : OK. How does SIDS occur?

Jeri Wilson : Well, researchers are saying now that SIDS occurs because the baby has low oxygen levels and higher carbon dioxide levels, and for some reason, vulnerable babies, these certain SIDS babies don't take that breath that we take when we are sleeping and we take the grasp, you know, to breath in. These SIDS babies don't have that ability, for some reason, so they can't kind of wake themselves up and breath, and so they're slowly kind of turned off. And that's one of the reasons why SIDS babies can't be resuscitated. I met a woman at the store a few months ago who said – I told her I was a SIDS educator – and she said “Oh, I'm a SIDS baby” and I said “Really? You look pretty alive to me”. So basically, if your baby stops breathing and it's able to be resuscitated, that's another event. If your baby stops breathing and is not able to be resuscitated, that's a SIDS.

KC Wilt : What age frame are we talking about with babies?

Jeri Wilson : The age is one month to one year, however, the highest rate of death occurs between two to four months of age. So, researchers are saying that there's a triple risk model for SIDS babies. The first one is development, so two to four months of age, that's your first risk factor, the second risk factor is too much bedding, sleeping around the baby, not breastfeeding, overheating the baby, and then the third risk factor is a vulnerable infant. And we don't know how to tell which baby is vulnerable and which baby is not. So if you have all three of those, you're likely to have a SIDS event.

KC Wilt : I've heard for babies to die of SIDS, even if you hold them, and they still die?

Jeri Wilson : Oh, yeah. I've heard of stories, yes, I've heard of stories where a baby has died in the arms of their parents, in the arms of paramedics, and people that were perfectly capable of performing perfect CPR.

KC Wilt : Your baby passed away at a daycare. As a parent I guess you went through situations like “What if I was there if I had the baby in my arms, would that have changed things?”

Jeri Wilson : Yeah, I did first, but then I was educated by the public health cares, I found information that with SIDS babies there is really nothing you can do. So part of the conflict here is that we tell parents to safe sleep and do all these wonderful things, and your baby can still pass away from SIDS. Or you could do nothing like my mom, you know, my parents didn't know about back to sleep, they smoked around me, I wasn't breastfed, and I'm still here, so I think it's kind of like seatbelts for babies, you want to keep your kids safe in the car you put them in seatbelts, you want to keep your baby safe when their sleeping, so you put them on their back and follow the safety procedures.

KC Wilt : Yeah, you may never get in a car accident but always have your belt on.

Jeri Wilson : Right, exactly.

Sunny Gault : So, Jeri, how is the cause of death determined by SIDS?

Jeri Wilson : It's after a thorough death scene investigation, an autopsy and a review of the clinical history. When they can find no cause of death then it's ruled SIDS.

KC Wilt : What can we do as parents, 'cause I'm listening to these stories going, how do you prevent this? Can you prevent this and what can parents do in order to make sure this doesn't happen or to reduce that risk?

Jeri Wilson : Right, beautiful question. When you say “prevent” and “SIDS” in the same sentence, I know you don't know what you're talking about. So, if you hear anybody say “prevention” and “SIDS”, there are no such things.

KC Wilt : Because if your baby has SIDS, your baby has SIDS.

Jeri Wilson : Yes, because your baby is vulnerable, your baby's vulnerable and nobody can tell. So my guess is that you have to do all the right things, however, you can do all the right things and the baby still can die.

KC Wilt : I almost feel like its hopeless, is there hope? I mean, as a parent, I'm listening to this going “Well, if your baby's going to die, your baby's going to die” and then why do I bother putting them on their back, why do I bother doing this?

Jeri Wilson : Well, it's the same like the seatbelt, you know, we don't know if we're going to get in an accident, so we want our kids to be safe, you want to do the best thing possible for them, but you also don't want to stay up all night and not get any sleep and be watching the breath, you know, so you do all the bests things that you possibly can, and you keep your fingers crossed. And 1 in 1000 babies dies, so the statistics are...

KC Wilt : ...It's going to happen.

Jeri Wilson : It's going to happen, but you don't want to make yourself crazy either.

KC Wilt : What are some ways we can do to reduce our risk, you mentioned breastfeeding, sleeping on backs, covers...

Jeri Wilson : The American Academy of Pediatrics last year came up with safe sleep guidelines, you can Google that or there can be other resources you can find, HealthyChildren.org has them listed. But basically, breastfeed, don't smoke around the baby, have the babies sleep on their back, don't overheat the baby. You know, when I go to the mall in July and I see these little babies in their strollers, with hats on and blankets, I'm thinking “Oh my gosh!”.

KC Wilt : Well, you're so much more aware of it than anybody else, you see the world in a different way.

Jeri Wilson : Right, but I also can't go to people and rip their blankets and get their babies out of strollers... So, you don't want to overheat your baby, and you want to keep the crib safe and not a lot of things in the crib, so use a HALO sleep-sack.

KC Wilt : Can I ask, you know with the extra clothes and heating your baby's body temperature, how does that contribute to being a factor, what is it about, raising the baby's temperature that would trigger something?

Jeri Wilson : That's something that researchers are working on right now, they're doing studies with the babies they have been studying that passed away with SIDS and they're also doing studies on rats. For some reason, these vulnerable infants, when they are in a smoke environment, when they're on their stomach, when they're overheated, they tend to die more. So we still don't know all the reasons why.

KC Wilt : I think that's what makes this so scary, we don't know.

Jeri Wilson : Right, and the SIDS parents are scared to death to have more children, because, you know, I always say, “If it was the green blanket, I'll never use the green blanket”.

KC Wilt : Right, but when you don't know...

Jeri Wilson : You don't know, so SIDS parents that have children afterwards are very brave.

KC Wilt : And it's not necessarily hereditary or anything?

Jeri Wilson : No, the statistics are still the same, whether you have twins or whatever.

KC Wilt : Thanks so much, when we come back we'll talk about resources for parents who've lost a baby to SIDS and answer more of these questions as we come back.

[Theme Music]

[00:14:04]

KC Wilt : Today on Parent Savers we have Jeri Wilson, she's a SIDS educator, and she is helping us understand what SIDS is all about. So, is it ever safe for your baby to sleep on their stomach and what if they roll over, I mean you say from zero to one, well I just think of like my baby crawling and everything else but still strong enough to lift their head up and take a breath, roll over...

Jeri Wilson : Well, we want to get in the practice of putting our babies on their back to sleep. The rate of death, let's say if you put your baby on his back to sleep all of the time and suddenly he goes to the daycare and or grandma's house and they put the baby on the stomach, that risk of dying is eight times increased.

KC Wilt : Eight times more?

Jeri Wilson : Excuse me, 18 times more!

KC Wilt : Oh my goodness! Just that one time?

Jeri Wilson : Just that one time. So we want to make sure that grandparents are educated, babysitters, cousins, aunts, anybody taking care of the baby has to be educated on this.

KC Wilt : What if the baby roles over?

Jeri Wilson : Well, for me, the first time my subsequent daughter rolled over my husband and I kind of freaked out, and we stood over the crib, watching her and thinking “What are we going to do?”. So we flipped her over and she got very mad at us. So we decided, and we consulted the experts too, that once they can role over, you let them role over. You don't want the baby to be spending the majority of their first year being flipped over and being mad.

KC Wilt : It could be bad for everyone.

Jeri Wilson : Yes. So two to four months is the increased rate, try to put them on their back, or put them on their back from two to four month, and after that, if they role over, you let them role over. You want your baby to be safe, but you want you and your baby to be sane also.

KC Wilt : Yeah, but I'm thinking like, 'cause both my kids seem like they love, I actually like to sleep on my stomach. I'm one of those weird people, that's just the prefered position for me. And so I find my boys like to automatically do this. They do right in my presence, I put them on their back and they flip over. And I'm like a bad parent if I walk out of the room, do I need to flip them at least once, and then run out on the door? And they're going to flip over again, but if I don't see it, somehow it's better for me.

Jeri Wilson : I think you just have to like I said before, you have to do the best you can. If it makes you feel better to flip the baby over after four months than I think that's OK.

KC Wilt : Or do you prop up like Buddha position so they can't roll over? You don't recommend anything else?

Jeri Wilson : No, there's a possibility that they role over and they stuck and get suffocated, you don't want that either, so you don't want them on their side, ever, you don't want to prop em up with a positioning that, you know, if you go to the stores they will say that this prevents SIDS. You want to teach them to sleep on their back, and let them flip over after they get older.

KC Wilt : So then my question earlier, as they start to get older, after one year, are those deemed maybe more SUID rather than a SIDS?

Jeri Wilson : Yeah, they just do, I don't know, we wonder that too, I actually have a friend in San Diego who lost the baby at ten months, and it was a classic SIDS case, so you don't know. It's one of those crazy, insane things that we have no idea about.

Sunny Gault : I think it's scary, that's why I brought it up, as I said, you feel helpless as a parent, you want to do whatever you can and like you said, if it's a green blanket you get rid of the green blanket; when you don't know what the green blanket is...

KC Wilt : All I'm thinking is, “I'm so glad my child's two!”

Sunny Gault : And I'm thinking “I have a seven months old one, oh crap! I thought I was clear and now I know I'm not!”

Jeri Wilson : Right, but you also don't want to make yourself crazy.

KC Wilt : You're right, because there are many more babies who don't die of SIDS. So is there any correlation to other things, like shots or choking or smoking in the house? I mean you already mentioned smoking.

Jeri Wilson : Right. Parents are not to blame, and that's the most important thing that we can learn and talk to new parents about. It's not their fault. You know, it's a random thing, the baby is vulnerable for some reason, so the parents should be released of their guilt as soon as possible. There is no correlation between shots, but if you think about it, the baby gets the most shots between two to four months of age, which is the highest risk, so there have been a lot of studies that have tried to connect those two and there's no correlation.

KC Wilt : When I was reading on my vaccine books, the extreme anti-vaccine books are all... they can claim story after story about a child who got shots and then that same night or the same day they died of SIDS. It made me freak out of getting any shots whatsoever.

Jeri Wilson : Right. If that worries you, maybe you can delay the shots a little bit.

KC Wilt : But then also the thought of other diseases...

Jeri Wilson : It would be something that you'd want to talk to your doctor about, but it really cracks me out when people talk about shots related to SIDS because I'm really active in the SIDS community and I have been for 20 years and we think that's just a joke. So, if anybody brings that up...

KC Wilt : You don't see much correlation between the two?

Jeri Wilson : No.

KC Wilt : OK, then about choking and anything, their own saliva?

Jeri Wilson : Well, that's the thing why a lot of parents and grandparents won't put their babies on their back, because they think they're going to choke, and spit up and die. They've done a lot of studies in the last few years, and there has been, again, no correlation. In fact, there's a public health center that I know who has wonderful slides that show the anatomy of the baby, and actually, the baby is better of spitting up if they're on their back, it's just the way the anatomy of the baby is. The problem is that grandma still thinks this, and great grandma's, so you finally have to educate them so that they don't put the baby on their stomach to sleep.

Sunny Gault : And I have another question, is there any correlation to specific ethnicities, or male/female babies?

Jeri Wilson : Good question. Do I really want to freak everybody out?

KC Wilt : I think we're already freaked out, so...

Jeri Wilson : For some reason, baby boys die more than females, for some reason, although in the past it's been more in winter.

KC Wilt : How much more? Are we talking about something significant?

Jeri Wilson : It's almost 50-50. Native-American and African-American babies for some reason die more often from SIDS. We don't know why we're researching.

Sunny Gault : Does baby weight have anything to do with it?

KC Wilt : My first born was 19,2 when he came out, so he was a pretty big baby, and I found, in general, he could move as fast and do that, 'cause I'm thinking that if he felt like suffocating or something, he might not be able to move as fast as a smaller child.

Jeri Wilson : You know, my daughter that passed away was 16 pounds at three months, so she was a chunk, so I would wonder that too. However, I remember going in and checking on her at night when she was crying, and she was lifting her head up, she was a strong baby. So, there haven't been specific studies on weight, so I'd be interested in that, especially since mine was a big girl.

KC Wilt : You can beat yourself out over it, I'm sure you did, and anybody who suffers from having lost a baby with SIDS. How do you, as a parent, recover from a nightmare like this?

Jeri Wilson : Oh, gush!

KC Wilt : How do they continue to have a second child? Again, without freaking out that they're going to have SIDS again? Also, is that a corelation, if you have one child who dies of SIDS, do you have chances of having a second child to die of SIDS?

Jeri Wilson : No, the rates are still the same, and that's what my husband told me about subsequent baby, 'cause I was worried and he said “No, I've done research and the rates are the same so you don't have to worry”, so I held that in my head for the first six months. For me and for parents that I have worked with, the most important thing is to get educated right away and to find out that there is nothing that you did or did not do that caused the baby to die, so we want to relieve the parents of that guilt that they're going to be carrying around. You don't want them to carry it around. I would just find other SIDS parents anywhere that you can, online, on Facebook, in your community, there are lots of resources in the US that will connect you with other SIDS parents. Because if you're sitting in a room and somebody next to you says that they're grieving by screaming in the shower in the morning and you go “Hm, I'm OK then!”, you know, hearing somebody else's story really normalizes it for you and helps you go on. Because SIDS is a really scary thing and you find that a lot of people at your work, your neighbors, your kid's friends don't want to talk to you, they don't know what to say, and so you're very isolated after your loss.

KC Wilt : Well, that kind of leads us into another interesting question, if you know someone who has gone through SIDS, a family that has gone through SIDS, how do you talk to that family? How would you have wanted people to talk to you and your husband shortly after?

Jeri Wilson : I had an amazing girlfriend who was very blunt and open with me, and asked me questions, like “How do you feel about going to the store and seeing baby stuff?”, you know, “How are you going to deal with being invited to that baby shower?”. So just keep the conversation open. If you are worried about asking somebody how are they doing and you don't want to upset them, and you avoid the question, just know that they're already upset, and anything you say cannot upset them any more. So you just want to keep talking, keep the conversation, “How are you doing today?”, you know, don't offer them, let's say, “Just let me know when you want me to come over and help you”.

KC Wilt : Yeah, that's too vague, yeah.

Jeri Wilson : You want to say, “I'm going to come over Tuesday and cook you dinner”, “Wednesday we're going to go out shopping”, so be supportive and offer, and keep the conversation open. And I've had a lot of people email or call me saying, “My friend lost a baby and they need support”, so I think those are the precious, precious people in their lives that reach out for them. What I've learned is that our society is very grief-stupid.

KC Wilt : Oh yes. We just, we freeze, we don't know what to do.

Jeri Wilson : Right. We don't know what to say.

Sunny Gault : Or we say “I understand”, and you don't.

Jeri Wilson : Right, you don't understand. So that's why, for me it was... I sought out anybody who'd lost a baby, because I wanted to know, I wanted to be comfortable talking to them, I wanted to talk about my daughter's life, if you lose a child that's 23 you have all those memories; you lose a three-month-old you don't have the memories and suddenly nobody wants to talk about her anymore. I needed somebody to talk to about her.

Jeri Wilson : That's a really good point.

Sunny Gault : And I loved how you and Bill have mentioned their names. You know, like, they have a name, they have a face.

Jeri Wilson : Oh, sorry, Jenelle.

Sunny Gault : In my story, I read about your past, but I love that, the names were mentioned, that was important.

Jeri Wilson : Yeah, it's very important. It's also very interesting that nobody really mentions her name anymore, but when I'm in target and they page Jenelle over your overhead I'm like, “Aww!”, and I know another mom who orders her coffee in her baby's name.

Sunny Gault : Oh my goodness, I just got the chills.

KC Wilt : That's so sweet.

Sunny Gault : It it is, 'cause it was a person, and you carried them, even though they lived only for three months, you carried them for 40 weeks, a part of you.

KC Wilt : Thank you so much, Jeri Wilson, for helping us learn about Sudden Infant Death. If you want more information, go to the today show page on our website. Our conversation will continue with Jeri after the show for our Parent Savers Club members, we'll be talking about safe sleeping. See our website to sign up.

[Theme Music]

[00:25:55]

[Featured Segments: The Emotional Side of Parenting]

KC Wilt : Before we rap put today's show, here's psychologist Jennifer Schere, with tips of understanding the emotional side of parenting.

Jennifer Schere : Hi parent savers! I'm Doctor Jennifer Schere, a clinical psychologist with a practice in San Diego. A large focus of my work has been on helping women during pregnancy and throughout the transition to motherhood. Today's topic is strategies to redefining boundaries with your own mom and other family members once you have a baby. An important thing to consider when becoming a new mother is what you want for your own mom, and then doing the big girl job of communicating that. Some women want they mother's support during delivery or right after bringing the baby home. Other women want the birth experience to be shared with spouses only, and feel strongly about having private bonding time. It is helpful to think through your needs and to communicate this ahead of time to family members. This allows time for feelings to get sorted out, and expectations to become clear to everyone. Many of us have mothers and relatives that are all too eager to jump in and voice their opinions, however, when we are vulnerable and sure of ourselves, we often want reassurance and validation. It is normal to feel sensitive or criticized by others' instructions on how some things should be done. New grandmas are adjusting too, they may become overinvolved due to a desire to feel close and maintain a purpose in the new family constellation. Everyone is going through loss and the very time that everyone is gaining. As a new mom, it can be helpful to think of yourself as CEO of your family. Use your relational intelligence to put the right personalities in their right roles. If a mom or an aunt is good at doing it, let her stop the fridge and manage the baby supply list. Perhaps you can do research on baby nutrition or pediatricians, put your people to work in ways that they can feel meaningful too. But know that you make the final decisions, and allow your intuition to guide you. It is part of forging your own path and defining your maternal authority. Thanks for listening to today's segment, and keep listening for more episodes on how to thrive as a parent.

[Theme Music]

KC Wilt : That raps out today's episode, we'd like to hear from you. If you have any questions for our expert about today's show or the topics we discussed, call our Parent Savers hot-line at 619.866.4775, or send us an e-mail through our website parentsavers.com or Facebook page and we'll answer your question in an upcoming episode. Don't forget to tune in to behind the scenes Parent Savers Club to keep listening. Next week, we're talking about ways to get the most out of your work benefits to help you and your baby. Thanks for listening to Parent Savers, empowering new parents everywhere!

[Disclaimer]

This has been a New Mommy Media production. Information and material contained in this episode are presented for educational purposes only. Statements and opinions expressed in this episode are not necessarily those of New Mommy Media and should not be considered facts. Though the information in which areas are related to be accurate, it is not intended to replace or substitute for professional, Medical or advisor care and should not be used for diagnosing or treating health care problem or disease or prescribing any medications. If you have questions or concerns regarding your physical or mental health or the health of your baby, please seek assistance from a qualified healthcare provider.

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