Toddler Development

This will only happen when your child is ready! She needs to know what doing a poo or wee feels like, to be able to tell you when she feels the need to go: and have the necessary bladder and bowel control to hold on long enough to get to the toilet. This may be any time between 18 months and 4 years. The first indication that she is ready may be that she starts pulling at her nappy when it is soiled. Staying dry at night may not be achieved until much later than daytime control. Toilet training doesn’t happen overnight so choose a period when you have time to devote to frequent visits to the toilet.

• It can help if she watches you in the toilet, she’ll learn by copying
• Summer is a good time to start – with less clothes to remove.
• You may want to use trainer pants – easier to remove, and more grown up than a nappy!
• Let her choose a potty or toilet seat.
• Take her to the toilet frequently; don’t ignore any requests to go!
• Praise her for even just sitting there for a short time.
• Lots of praise and cuddles for a wee or poo.
• The incentive of new underpants can be quite compelling.

It is normal for a toilet trained child to have accidents, or to revert to nappies, if for example, a brother or sister arrives in the family. Be patient and help her when she is ready again. You may need to check with your doctor that your child does not have a urinary tract infection Try not to take any notice of behaviour you don’t like or want. Words can hurt children. They believe what you say, so saying they are stupid doesn’t help them. Tell them it’s what they are doing that you don’t like, not them.Don’t expect too much of him. Toddlers are only learning to understand.Remember to teach hand washing after every visit to the toilet

Feet

It’s been estimated that a person will walk approximately 115,000 miles in their lifetime (8-10,000 steps a day) and research tells us that approximately 90 per cent of children have problems with their feet. The first few years of life, in particular, are crucial as the bones in your baby’s feet are formed from soft, pliable cartilage which makes them more susceptible to malformation.

Tight shoes, socks and even bedclothes can bend the soft bones in your child’s feet out of shape and cause long term damage. Your toddler doesn’t need shoes until they are walking outdoors and even then they can be taken off indoors. Toddler feet grow fast . Check your child’s feet regularly.They may need the next shoe size up within 6–8 weeks.

When buying shoes check that:

• they fit. Feet should be measured every time and shoes fitted to the largest foot
• there is growing space at the toe
• they will stay on when your toddler walks or runs
• they are comfortable
• they are flat- to support your child’s feet
• shoes aren’t too heavy on the child’s feet
• don’t keep shoes for “best” as they will soon be too small

Remember – canvas shoes are just as good as expensive leather ones!

Talk to your health professional if:

• your child persists in walking on tip-toe rather than flat on their feet
• by the age of two years there is still a clear gap between your child’s knees and ankles when they stand.

Tantrums are emotional explosions, usually caused by anger or frustration when your toddler isn’t able to do the things they want to do – climb that step, have that toy or put their coat on by themselves. Sometimes tantrums are caused by confusion or fear because toddlers have a limited understanding about the world.

Older children can do the things they want to do or at least talk about it, but toddlers often can’t express themselves . Throwing a tantrum may seem the best solution! Some toddlers also learn that it’s a good way to get what they want and so throw a tantrum whenever there is an audience.

Because toddlers lose control during a tantrum, they sometimes scare themselves. They may scream and shout, fall on the floor, bang their head against the wall, throw things or hold their breath. Don’t worry – it’s impossible for a toddler to harm themselves with breath-holding.

Once the explosion of frustration is over, they may well cry and feel very sad and lonely. The whole experience can make you feel scared and angry, but your child needs you to stay calm and in control.

Avoiding tantrums

Your toddler may rarely have a tantrum, while others are prone to having several every week. If your toddler has a lot of tantrums try to work out what might be the cause. Things such as tiredness, hunger, having to finish what they’re doing to move on – going home from the park or leaving playgroup – can spark them off.

Hannah: ‘Lucy only had to see a supermarket trolley to start a tantrum! Then I realised we did the shopping late in the afternoon when we were both tired. We swapped to mornings, which was better. Not perfect …but better.’

If you can anticipate the problem, you can try to avoid it. Make sure they have a drink or something to eat if they are hungry, or have a quiet time reading a book together if they are tired.

If stopping doing something is the problem, try to make it attractive – play at racing to the park gates, go to see the pigeons/lambs/digger trucks on the way home from playgroup.

If they are having tantrums often, look at their daily routine and see if there are ways to change things around so that life is easier for them. Some toddlers fall asleep after a tantrum, having exhausted themselves. This may be a sign that tiredness is partly the cause.

How many, how long?

Toddlers may have anything between two tantrums a day or three tantrums a week. Some have as many as five a day. Most tantrums last about three minutes, but the older the toddler, the longer they can last. Most children outgrow tantrums by the age of about five years. Seek help if your child is still having them often at this age.

When your toddler has a tantrum

Take a deep breath …..

The key thing is to deal with a tantrum calmly (even if you have to go away and recover afterwards yourself!) Try not to shout or lose your temper as this only makes your child feel more frightened.

You also need to teach them that tantrums are not a good way to get what they want. If they have a tantrum to get a chocolate bar or toy, and you give them a chocolate bar or toy, they will have a tantrum next time they want one. You don’t want them to learn that tantrums lead to getting their own way.

Ways to cope with a tantrum:

• do not try holding the child while they are shouting and kicking as this may make them even more angry. You may simply need to wait nearby until the worst is over and then hold them when they are crying and feeling sorry
• they will need your comfort afterwards – a hug, a rock on your lap and gentle reassurance ‘It’s all over now, have a hug with mum, let’s just cuddle for a while’ will help them calm down
• put into words how you think your toddler is feeling. They cannot express themselves but if you say ‘That made you very cross didn’t it? And now you feel all wobbly…’ it will help them cope with their feelings
• After the tantrum take some time out yourself to recover.

Immunisations

Your child may need extra immunisations if you are travelling overseas. See your GP or a specialist travel doctor six to eight weeks before you intend to travel, especially if visiting developing countries, as some vaccinations have to be administered in several doses over several weeks. If backpacking or going for a longer period see your doctor three months in advance. This is not just a personal health issue. There are countries which require their visitors to have received certain vaccinations. Also, there are countries which recommend medications that should be taken to lower the risk of getting highly prevalent diseases for which there are no vaccinations.

If you are going to a part of the world where there is malaria, a serious infection caught from mosquito bites, your child will need protection against that, too.  Malaria is a problem throughout the tropics and can kill. Anti-malaria tablets should be taken from one to two weeks before travelling and must be continued for four weeks after leaving a malaria region.

Care in the Sun

New Zealand has one of the highest rates of skin cancer in the world. Exposure to sunlight in childhood is the main risk factor for melanoma and other types of skin cancer. Toddlers can burn easily in the sun so precautions to avoid this are vital.

• damage to the skin is caused by UV radiation (UVR) from the sun. UVR can’t be seen but it can burn and permanently damage the skin.
• babies and toddlers have more delicate skin than older children and adults and will burn more easily.
• we all can burn even if it is cloudy or if the sun doesn’t feel very hot.
• the sun can be particularly intense from  October through to March in New Zealand.
• the sun is strongest between 11am and 4pm during the months of daylight saving.
• keep your child out of the sun between 11am and 4pm as much as possible.

If you go outside:

• stay in the shade.
• cover the stroller/pushchair or play area with a shade cloth or thickly-woven blanket.
• dress your child in a broad-brimmed hat and close-woven clothing that covers the arms and legs.
• use only ‘approved’ umbrellas and light coverings as many brands can let the sun through and are unsuitable for proper protection.
• use broad spectrum (30+) sunscreen on parts of the body that are uncovered. Apply evenly and re-apply frequently.

In the sunshine?  Remember to:

• SLIP on a top
• SLAP on a hat
• SLOP on a good sunscreen
  More information is available from www.sunsmart.org.nz/

Travelling Tips

Here are a few tips to make travelling with children a little easier:

• if flying ask for bulkhead seats with a bassinette.
• choose appropriate accommodation such as self-contained motel units or apartments with two or more bedrooms.
• if you’re renting a holiday home or villa, does it have a pool? You’ll need to be extra watchful if it does.
• even if your holiday company is offering ‘free child’ accommodation, it doesn’t necessarily mean that it’s ‘child-friendly’ so check to see what’s on offer.
• hire furniture items such as a stroller, cot and high chair, rather than cart your own.
• use disposable nappies.
• use babysitting facilities at your accommodation so you can have a break.
• remember that the price of children’s clubs at some resorts is an extra expense.
• pack sunscreen, hats and insect repellant.
• pack sensible toys, particularly the special one. Offer toys one at a time, replacing each toy with a fresh one once the child shows signs of boredom.

Passports

All children require a passport when travelling overseas

Passport office

0800225050

http://newzealand.govt.nz/

Keeping children safe while the family gets from point A to point B.

Car

• always use car seats or booster seats.
• don’t stack items on the back ledge of the car or over the steering wheel as these items will become dangerous flying projectiles if you have to brake suddenly.
• use shade cloth to keep the sun from shining in your child’s face.
• plan for plenty of toilet stops. Frequent rest stops help reduce the risk of motion sickness.

Bus or train

• use seatbelts if available.
• don’t allow your child to crawl or walk around while the vehicle is moving because they may fall. Keep your child seated or on your lap.

Plane

• try to feed your toddler while taking off or landing as the frequent swallowing can help prevent the buildup of pressure inside the ears.
• encourage your child to drink plenty of fluids to reduce the risk of dehydration.
• pre-arrange children’s meals when you book the flight.

Unfamiliar meal routines

Toddlers are notoriously fussy eaters. Travelling to unfamiliar places with new foods and different mealtime routines can further disrupt your child’s eating habits

Relax and remember that a healthy child will never voluntarily starve themselves. Trust them to eat when they’re hungry. Follow these safety tips when visiting a developing country:

• avoid salads, raw vegetables, shellfish, locally made ice cream, unpasteurised milk and dairy products
• drink bottled water and avoid tap water and ice in drinks
• eat only food that’s freshly prepared and is still hot
• peel all fruit yourself
• try to keep a little bit of familiar mealtime routine, such as having breakfast in the usual way
• don’t assume you will always find something your child will like on a restaurant menu
• carry plenty of their favourite snacks and drinks when touring
• see if the restaurant you’re planning to visit has a children’s menu
• if you are unsure of the water supply only drink bottled water or bottled fruit juices
• use bottled water when brushing teeth
• wash your child’s hands frequently – carry hand sanitiser lotion.

For toddlers play is serious business – it’s the way in which they learn how the world works. While they play, they learn. You can be the best teacher your child will ever have and it can all be done through play. When your children play with you they feel loved and important and feel they are fun to be around. These social/emotional skills give them the self-esteem and self-confidence they need to continue building loving and supportive relationships all their lives.

Some Milestones

Your toddler is remembering more and figuring out how things work.

At around one year old most toddlers:

• are able to wave ‘bye-bye’
• search for a lost toy because they can remember it
• point to their nose, tummy or the dog when asked to.

You can encourage development by:

• lots of interaction – point out animals, colours, shapes
• talking to them – they will try and join in the conversation
• giving them shape sorter toys, push along toys, building blocks, pegboards with large coloured pegs
• praising them – they will love to show off their new skills (like waving)
• providing simple jigsaw puzzles to help them develop basic problem-solving skills as well as hand-eye coordination.

Around 18 months most toddlers:

• parallel play – play near others but not with them
• have seemingly endless energy and capacity for making a mess
• are much more steady on their feet
• are able to build a tower of three or four blocks
• go back to a game if interrupted
• talk to themselves as they play

You can encourage development by:

• letting them explore in a safe environment
• reading to them (rhyming and repetition are especially good)
• singing and dancing together
• getting them together with other children

They will imitate whatever you are doing. This is a time for lots of hugs and cuddles.

At around two years most toddlers:

• are able to put simple shapes through holes
• start climbing
• remember when you do things
• sit on the bottom step when it’s time to put shoes on
• fetch a book for story time
• know names of body parts

By three years most toddlers:

• find it difficult to control their feelings, which often results in a tantrum
• find it a challenge when asked to wait
• are able to do large-piece jigsaw puzzles
• act out versions of the real world
• pour a cup of pretend tea
• take toys for a ride
• begin to share.

All children are different and develop at different rates, so don’t be overly concerned if your toddler is acquiring new skills at a different rate to those around him.

Social Time

Children usually settle more easily into school life if they have spent some time in a playgroup or preschool setting. In New Zealand, the main providers of early childhood education are kindergartens, play centres, Pacific Islands language groups, education and care services, home-based care services and köhanga reo.

In the toddler years, combining childcare with early learning becomes more important. In a playgroup or pre-school, toddlers learn some of the skills they need for school and also how to behave in a group – sharing toys, having quiet times and playtimes, and getting along without mum or dad. When you visit a childcare centre or playgroup that you’re thinking about for your toddler, look to see:

• are the children happy and relaxed, enjoying themselves?
• are the staff friendly and welcoming?
• is the building and outside play area safe and attractive?
• are the available activities interesting?
• is the centre’s atmosphere colourful, fun and creative?
• is there good lighting, ventilation and heating?
• is there an area for messy play, a space for book reading, a dress-up area etc?
• what is the routine for meal/snack times and who provides the food?
• the toilets/changing areas.

Help your toddler settle in:

• visit several times before you leave them there
• let them play while you are at the other end of the room
• stay for just half an hour the first time
• tell them that you are going and when you will come back
• stay calm and positive yourself (however you feel inside)
• come back when you say you will.

Make sure your childminder or pre-school know their likes and dislikes and leave their favourite toy or cuddly if they need it to fall asleep.

Making Friends

For toddlers making friends is like walking. At first, they need a lot of support. Later, they can’t wait to charge off on their own.

Most toddlers enjoy having other children around. Until the age of about three, they play near others rather than with them but will form strong attachments to children they see regularly. At this age toy sharing isn’t an option – one or the other will have to have it, or an adult will have to take it away and keep the peace. Even the best of friends of toddler age can be hurtful to one another –social skills take time.

“My daughter prefers to play alone and won’t play with her friends.”

Toddlers do not show much interest in playing together with other children until they are around 3 years old. Instead, they tend to engage in what’s known as parallel play. This is where the children play next to or alongside each other. To you, it looks like playing alone but if they are happy, leave them to it.

Between the ages of two and three years, most toddlers enjoy spending some time each week in a group of children. They learn to make friends with adults on hand to organise activities, sort out squabbles and read stories. Check notice boards or ask your Plunket nurse or Well Child Health provider for details of playgroups in your local area. A couple of sessions a week could be just the social event your toddler needs!

What not to worry about – shyness with other kids

Some children are naturally more introverted than others, especially around strangers, and need more encouragement in social situations. Try instigating a one-to-one play date in your home rather than large toddler group and prepare your child for what’s going to happen in advance, talking about who’s coming and what you’ll all play with.

The Art of Sharing

Your toddler won’t share! The good news is they are not selfish or spoilt and they won’t grow up to be antisocial. They are simply acting their age. The reality is, few children react well when someone else dares to take their things. But don’t give up – there is a way to teach your child the finer points of sharing.

Sharing is a skill a child has to learn

Sharing is very difficult for small children to grasp, mainly because they feel the world is about them,  so why should they let another child play with what is obviously theirs? The good news is you can coach your child to share. Imitation is your best tool. If your child sees you, your partner, family and friends sharing, they will see it as a normal way of behaving.

However, there are very distinct stages of child development that will affect your child’s ability to share successfully:

• between 0 – 1 1/2 years your child is likely to play alone and not understand sharing at all.
• from 2 – 2 1/2 years your child will play side by side (parallel play) with another child and with your help can begin to grasp the idea of sharing.
• from 2 ½ – 3 years your child will begin to interact with other children and may share without being encouraged.
• above 4 – 5 years your child will show a preference for friends and play happily with other children with the concept of sharing becoming more natural.

What’s the best way to teach my child to share with another child?

Aside from imitation and praise for your child when they share, it’s important to assure your child that sharing doesn’t mean giving away a toy forever. Many children think if they share they will never see a toy again.

If your child doesn’t want to share something – don’t force them or punish them, as this won’t teach them anything. Not sharing isn’t a reflection on your parenting or your child’s personality (even if it feels that way). It’s simply a sign your child isn’t at the right stage to share yet.

The best way to encourage your child to talk is to include  them in everything you do and see together. Speak directly to your child. Repeat words and explain things. Let them match what you say to what they can see, what you’re doing, to your facial expression. Avoid the use of dummies as they can delay speech development. If English is not your first language just use the language you know best. Children can learn to speak in two languages at once, more easily than adults.

By 18 months – usually:

• has vocabulary of approximately 5-20 words
• vocabulary made up chiefly of nouns
• repeats a word or phrase over and over
• is able to follow simple commands

By 2 Years – usually:

•  can name a number of objects common to their surroundings
• can combine words into a short sentence – largely noun and verb combinations
• approximately 2/3 of what your child says should be intelligible
• has a vocabulary of approximately 150-300 words
• rhythm and fluency often poor
• volume and pitch of voice not yet well-controlled
• can use two pronouns correctly: I, me, you, although me and I are often confused
• responds to such commands as “show me your eyes (nose, mouth, hair)”

Support your toddler by talking to them. Talk about colours – ‘Where’s a red car?’ Count together 1, 2, 3, etc (especially if it can be related to real life – while supermarket shopping.)

If you are worried that your child is not talking as early or as well as other children, particularly if they are not talking at all by two and- a-half years, it’s worth checking that they can hear properly. Ask your health professional for a hearing test. If your child cannot be clearly understood by the age of three years, they may be referred to a speech therapist for help before they start school.

Your toddler still needs almost as much sleep as they did when they were younger, usually around 11 hours at night until the age of two years.

Until around 15 months your toddler probably has had two naps a day (around 1 -1.5 hours each), but by 18 months they may have just one sleep in the afternoon. This afternoon nap might last until they are around four or five years. If not, it is good practice to have them lie quietly with a book or a safe toy.

If you’re still being woken at night or you have difficulty settling your toddler to sleep, you’re certainly not alone. Many parents have problems with their child’s sleep that last well beyond the first year.

Strategies to improve the situation are those that you might have used when your child was younger and they’ll still work now:

• make sure they follow a bedtime routine.  Toddlers enjoy knowing what’s going to happen and like to keep the same order it makes them feel secure.
• try a warm bath (not too hot). Sitting in warm water is a soothing experience and getting your toddler warm and clean and dry is a great way to ease them into bedtime. A bath is also a wonderful way for your partner to spend some special time with your child.
• into bed for a story with a cuddle. For a toddler, choosing a bedtime story is another chance to assert some control over the nightly routine.
• stick to the same bedtime and naptimes each day. If your child knows when sleepy-time is they are more likely to fall asleep on cue.
• let your child fall asleep on their own. If you lie down with them each night or sing them to sleep, they will need you to do the same when they wake in the night and will call for you to do so.

There may be renewed anxiety about keeping you within sight. Your child may already have a soft toy or a bit of blanket. Now it acts as a true comforter to help with the separation anxiety. Make sure it is tucked up with them.

Many children overcome bedtime fears with a nightlight left on in the bedroom, the door left ajar, or a radio playing softly.

If your toddler has become used to you settling them to sleep, teaching them to fall asleep on their own may not be easy. Many parents try a structured approach – when you leave the room and they start to protest, you wait five minutes before going back in, then ten minutes, and so on. The aim is to reassure them that you are still there but that sleeping is something they can do all by themselves. Toddlers have more staying power than babies so it may take a few nights. Get support from other parents or a sympathetic relative if you do this. Unhappy evenings can be a strain. But it will work and the whole family will sleep much better for it.

As your toddler gets a little older they may decide to try delaying tactics. Two favourites are “I want a drink of water” and “I want to do a wee”. Be patient, firm and consistent. Put them back to bed and make sure they understand it is sleep time!

Never tie a child to the bed or lock the bedroom door.

From Cot to Bed

Many parents move their child into a bed between the ages of two and three years, usually because the cot gets too small. It is also a good idea to move a toddler into a new bed a couple of months before a younger brother or sister is due, so the new baby isn’t seen to be taking over “their” cot. Once in a bed, you may find that they’ll get out of it – just because they can. If they disturb you take them back to bed calmly but firmly, again and again, until they understand that beds are for staying in. If you lose your temper you’ll be giving them attention and possible entertainment, so stay calm.

The first molars, which usually come through at 12–15 months, and the second molars, which appear towards the end of the second year, are big teeth. Your toddler will get twenty of their primary (baby) teeth by the time they are about three years old, usually at the rate of three to four new teeth every four months. Teething often causes the child to dribble and like to chew on hard objects. This can cause mild pain and irritability and gums may be swollen and tender. You can gently massage the gums and/or give them something smooth and hard to chew on. Teething does not cause fever, diarrhoea or nappy rash.

Children’s paracetamol may also ease any inflammation. Read the dosage instructions carefully,  Ideally, you should calculate the dose of Paracetamol for your child based on their weight.

Never exceed the maximum dose. Never give aspirin to a child under 16 years old.

Taking care of your toddler’s teeth is important. Set a good example by letting them see you clean your teeth every day. Clean their teeth twice a day using a soft brush and just a smear of baby toothpaste. Baby’s toothpastes are specially formulated with lower levels of fluoride than adult’s. However, ideally, these toothpastes should still contain no less than and no more than 1,000 parts per million of fluoride so always check the packaging. Your dentist may recommend fluoride supplements or using adult toothpaste in areas where the fluoride content in the tap water is low.

Try to use a circular ‘scrub’ technique when brushing, ideally, around each tooth – easier said than done with a wriggly toddler but it gives you something to aim for!

Show you care about your teeth and your toddler will copy you.  Make a game of it, let them brush your teeth, take turns and remember, generally children under the age of 8 years old need help brushing their teeth.

Bedtime Eating and drinking checklist:

• the only safe drink at night is water.
• avoid the prolonged use of milk or sweetened or acidic liquids in drink bottles during the day. Use cups.
• give cheese, bread and fruit as in between meal snacks.
• keep snacks sugar free.
• the best time to eat sweet food is during mealtimes.
• drink lots of water.

Sticky sweets and drinks play a large part in tooth decay, so encourage your toddler to have drinks from a cup, not a bottle, and always dilute fruit juices well (one part fruit juice to ten parts water) until one year old. Then gradually dilute less as your child grows. Take your toddler with you when you go for your dental check-ups. They will get used to the sights and smells of a dental surgery before they ever have to sit in the chair and open their own mouth!

As soon as your child turns one year old enrol them at the local school dental clinic and organise a visit to the school dental therapist. This is a free service that can provide you and your child with care and advice.

Understandably, when children wet the bed parents ask questions such as: why is my child bed wetting, what are the causes and how can I help?

Wetting the bed, or nocturnal enuresis, can be as upsetting for parents as it is for children. It may be of some comfort to know that wetting the bed is very common and majority of children will grow out of it. Generally, bed wetting can be categorised as primary nocturnal enuresis or secondary nocturnal enuresis

Five Reasons for Primary Nocturnal Enuresis

1. Bladder VS Brain – The bladder and brain have not yet developed that harmonious relationship where the brain responds to the signal that the bladder is full.
2. Family History – bed wetting can be genetic. Chances are that if one parent experienced nocturnal enuresis, their child is more likely to have the same experience.
3. Hormones – when you settle down to sleep, your pituitary glands release an anti diuretic hormone which slows the production of urine so your sleep is not disrupted by the need to urinate. Some children go through a stage where too little of this hormone is produced.
4. Small Functioning Bladder Capacity – some children have small daytime bladder capacity, when they finally fall into a deep sleep, their bladder will empty of its own accord when reaching that same small daytime volume.
5. Habitual – poor daytime toilet habits. Quite often children ignore the urge to urinate and hold off as long as they possibly can. They then have trouble recognising the urgency signals going from bladder to brain, at night time.

Five Reasons for Secondary Nocturnal Enuresis

Secondary nocturnal enuresis can suggest underlying health concerns

1. Urinary Tract Infection – resulting in bladder irritation that causes a stronger and more frequent urge to urinate. Quite uncomfortable, but luckily – easily treatable.
2. Diabetes – Type 1 diabetes means a high level of sugar in the blood
3. Emotional – stress can trigger bed wetting. Can be triggered by starting schools, moving house or the birth of a sibling.
4. Neurological – abnormalities in the nervous system can upset the oh so delicate neurological balance that manages urination resulting in nocturnal enuresis
5. Pinworm Infection – usuallycharacterised by intense itching of the anal/genital area.

Five Tips for Managing Bed wetting

Bed wetting can be an emotional experience for anyone – big or small.

It is important to remain cool, calm and collected during the bed wetting stage. In the hopes of making the entire process a little easier on your child and you, here are a few tricks to help with managing bed wetting.

1. Restricting fluid intake
2. Ensuring bladder and bowel are empty before bed
3. Using plastic under sheets to protect the mattress
4. Look into a bed wetting alarm
5. Use DryNites pyjama pants

In cases where secondary bed wetting persists or becomes unmanageable, it is advisable to seek a medical opinion.

Last but not least remember to provide love and support. A little bit of positive rein