Enclosed is a log of Monday nights breast feeding session on channel
pediatrics of International Pediatric Chat with special guest Tom Hale PHD
who wrote a book on medications and breastfeeding. Its called "Medications
and Mothers' Milk". Next week we will discuss criteria for baby friendly
hospitals.

LOG:
<Julius> Please introduce yourself and where you are from MikeW
<Julius> welcome mike
<MikeW> I'm Mike Webster, a PL3 resident from Akron Children's
<MikeW> Pretty empty house so far.
<Julius> welcome is this your first time
<Julius> not for another 10 minutes
<MikeW> No, I've been on a few times, but I am more of an observer
<Julius> we will have some members at 10pm
<MikeW> we have spoken once or twice
<Julius> are you registered
<MikeW> yes
<Julius> one of my partners is a graduate of Akron
<MikeW> John Hollerud introduced me to the list. You probably remember me now
<Julius> John Hollerud
<Julius> yes I do
<Julius> Are you interested in lactation
<MikeW> I have not had much luck recruiting other Akronites to the list
<Julius> keep trying
<MikeW> We have limited training in lacation issues.  I am trying to pick
up more for use in my practice in July
<Julius> great 
<MikeW> Do you know anyone in Erie, PA.  That is where I will be working
<Julius> we will discuss drugs and breat feeing and where to reference
questions
<Julius> no I do not
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<Julius> Please introduce yourself and where you are from Tom
<Julius> should be a pretty city with lots of snow
<MikeW> Good evening tom
<Julius> welcome tom
<Julius> we are jsut casually chating
<Tom> hi guys, just logged on to see if anyone here
<MikeW> Ther will be more soon
<Julius> Hopefully more in a few minutes
<MikeW> We are just early
<MikeW> Julius is always online, it seems
<Tom> This is my first chat session, so its rather new to me.. but i find
it rather interesting
<MikeW> It is a great way to discuss topics with a wide range of people
<Tom> julius,  are you an anesthesiologist
<MikeW> IPC has a pretty flexible combination of scheduled discussions and
impromptu chat.
<MikeW> I don't know where Julius went, but he is a pediatrician
<MikeW> I think
<Tom> oh,  I couldn't remember, but one of his last sessions was on
anesthetic agents
<Julius> I just sent a quick email reminder
<Julius> no I am a general pediatrician
<MikeW> Those reminders are a great idea.  I usually see them too late, though
<Julius> yes you should come to some of our other sessions and invite
pediatricians from your center and nurses too
<Tom> so,  do you have a special interest in breastfeeding, i noted the
last several session were about areas in breastfeeding.
<Julius> yes we had a session on anesthetics and nursing a few weeks ago
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<Julius> Please introduce yourself and where you are from drjim
<Julius> Please introduce yourself and where you are from DrSue
<Julius> I have started a breast feeding program at our hospital about 10
years ago
<Julius> sue you made it
<MikeW> Hi drjim, drsue
<Julius> welcome jim
<drjim> hi everyone 
<Julius> we wil start in a few minutes
<DrSue> Good evening Julius - This is Dr. Jerry Aronson. Dr. Sue will join
us soon!
<Julius> I'd like to give a couple minutes more for people to come
<Julius> Thanks Jerry 
<drjim> Jim Saperstone Priv Gen Peds Albany NY
<Julius> Julius Edlavitch General Peds Minneapolis Minnesota
<Julius> Tonight we will discuss medications and lactation
<Tom> Tom Hale, Ph.D. Clinical Pharmacologist Texas Tech Univ School of
Medicine, Dept of Peds
<Julius> lets first talk about pain relievers
<drjim> good eve Dr hale
<DrSue> Dr. Sue and Dr. Jerry are in a faculty clinical practice at St.
Christoher's Hospital for Children in Philadelphia.
<MikeW> Mike Webster, MD. PL3 General Peds. Children's Hospital of Akron.
<Julius> acetaminophen, ibuprophen codeine 
<Julius> what do you tell a mom who may be taking one of these
<Tom> Acetaminophen is probably fine,  amount transferring into milk is
quite minimal.
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<Julius> Please introduce yourself and where you are from snoopy
<Julius> how do you know this
<Tom> Ibuprofen is fine too,  of the NSAIDS,  it has a very short half-life
and the amount entering milk is only 0.6% of maternal dose.  Besides its
cleared for pediatrics anyway, at least older kids.
<snoopy> I am from Morrisville
<drjim> This is great news we all sort of felt this way Agrre ?
<Julius> now how about codeine and percodan
<Tom> How do I know this,  reported levels are only 10-15 mg/Liter of milk.
Reported dose to infant is only 0.04 to 0.23% of maternal dose.
<DrSue> Dr Sue has joined the conference with Dr Jerry.  Maybe we should
focus on what is not ok since so many drugs are safe per current literature.
<drjim> I'm pretty liberal with most meds lact moms take if they need them
Only a hand ful seen to be contrindicated ???? Dr hale comment ?
<Julius> great idea Sue we have an expert with us tonight
<Tom> That really quite accurate,  the number that are really
contraindicated are quite few.
<Julius> Tom wrote a book on this subject
<Tom> Oh,  I didn't want to let the secret out...
<DrSue> Are there any rules to go by about classes of medication. e.g.
antimetabolites are no good 
<Julius> Tom before we start could you introduce your book
<Tom> Its called "Medications and Mothers' Milk", it contains 500 drugs and
their use in breastfeeding situations. Its quite popular with the
Brestfeeding groups.
<Julius> Thanks now anser DRSUE's quesrtion please
<Tom> As for sue's question,  I generally consider antimetabolites quite
dangerous.  A good rule of thumb, is if its really toxic to the mother its
probably too dangerous to use with an infant.  Even though a lot of meds,
partcularly toxic ones, don't get into milk very well.
<Julius> What are some examples of antimetabolites
<Tom> You'd be amazed,  cisplatinin can barely penetrate milk,  but i still
think its too risky.
<DrSue> Are preterm infants more or less at risk to drugs in breast milk? 
<Tom> Antimetabolites such as methotrexate(for asthma, arthritis, etc),
immuran, etc.
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<Julius> Please introduce yourself and where you are from LAS
<Julius> What about premies
<LAS> I'm a LLLL and ICCE from Central FL
<Tom> As for age,  preterm  and term infants are most susceptible during
the first 2-3 weeks postpartum when the colostrum is being produced, and
the breast is easily penetrated by meds.
<drjim> I've always questioned the use of anti thyroid meds ???? justified
to be concerned ?
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<Julius> Good question jim
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<Julius> Please introduce yourself and where you are from shemesh
<Tom> For antithyroid,  actually PTU is quite safe,  thousands of bfing
moms use it quite safely.  Methimazole is a big no, no, however, since it
penetrates milk to a sign. degree.
<shemesh> good morning from Haifa Israel
<Julius> Welcome THe SUn from ISrael
<Julius> Bokar tov
<shemesh> Sorry I am late - boker or
<drjim> Interesting always told mom's to avoid if on PTU thanks....
<drjim> PREDNISONE ???
<Tom> The biggest danger for hyperthyroid moms is the use of I-131.  Iodine
concentrates in milk and has a milk:plasma ratio of 26.  High levels
concentrate in milk and increase risk of infant and increase risk
(theoretically) to breast cancer for mom.
<shemesh> still up to 40mg?
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<Julius> Please introduce yourself and where you are from vlady
<Julius> buenos Noches Vlady
<DrSue> What is behind the susceptibility of the breast to penetration to
drugs in the first two to three weeks postpartum or when colostrum is being
produced?
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<vlady> Vladimiro Alcaraz, generalist  pediatrician from Hermosillo,
Mexico, Director a a baby friendly hospital
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<Julius> Please introduce yourself and where you are from shemesh
* vlady saluda a Julius con un calido y amistoso abrazo y una sonrisa!!
Gusto en verte Julius!!
<shemesh> I fell off - sorry
<Tom> Drugs penetrate most during the first 14 days postpartum because the
secretory alveolar epithelium has not swollen and grown together, large
gaps permit transfer of live cells, macrophages, etc,  and drugs.
<drjim> So good and bad
<Tom> But at about 14 days,  prolactin from the pituitary swells the
alveolar cells and they sort of act like a blood brain barrier.
<Julius> We ar focusing on different drugs that may be a problem with the
guidance of Tom a Cliccal Pharmacologist From Texas who Wrote a book on
Drugs and Breastfeeding
<vlady> Casi todos los fármacos pueden pasar en mayor o menor grado a la
leche Materna, pero en cantidades mínimas (menos de 1-2% de la dosis
recibida por la Madre). El fármaco ingerido por la Madre, debe ser
metabolizado en el higado, de tal manera que finalmente la dosis consumida
por el Lactante queda en alrededor de 0.001 a 0.5% de la dosis terapéutica
tolerada por el Lactante sin toxicidad. 
<DrSue> Thank you Tom. That is new information and very interesting.
<Tom> How do you guys treat candidiasis?  Particularly resistant types.
<drjim> Lets get back to discussing other radioactive substance that may be
used in imaging lact moms
<Julius> Great question
<Julius> Lets finish the radioactive question and move on
<Tom> Are you asking about Technitium and other types ?
<shemesh> I also need info on candiasis - although we seem to have
exhausted all rx's
<drjim> yes
<vlady> Temporal suspension of breastfeeding RADIOFARMACOS QUE REQUIEREN
SUSPENSION TEMPORAL 
<vlady> Indio 111, Galio 67, Yodo 125, Yodo 131, Sodio radioactivo,
Tecnecio 99 
<drjim> few days ??
<DrSue> Candidiasis as oral thrush and nipple yeast infections are rarely
resistant, just recurrent.  When all else fails (once in 30 years of
practice) there is gentian violet.
<Tom> Most of the other radioactive compounds don't concentrate in milk,
but its a good deal to wait about 5 half-lives prior to restarting
breastfeeding.
<drjim> great ?
<Tom> I speak to lots of lactation consultants daily,  an I can tell you
the number one question, problem, they have is sore nipples, that they say
is from candidiasis.
<Julius> How often do you apply gentian violet
<DrSue> To keep it purple.
<Julius> do you use gentian violet on the nipples
<vlady> absolute not indicated in breastfeeding Bromocriptina, Ergotamina,
Cocaína, Litio, Ciclofosfamida, Metrotexate, Ciclosporina, Fenciclidina,
Doxorrubicina, Fenindiona. 
<shemesh> But Dr. Tom most often you have vaginal candida as wll
<Julius> cna you use it every day for weeks
<drjim> DiFlucan OK ?
<Tom> Gentian violet is a little irritable, and most people I know use it
sparingly, maybe a few times during a week
<DrSue> Once in 30 years I resorted to gentian violet everywhere (vaginal,
mouth, nipples) otherwise use of mycostatin everywhere has stood up well in
my practice.
<shemesh> we are seeing lately that people are using a .5-1% solution for a
short time
<Tom> As for the concentration, be sure to use the 0.5-1%,  anything higher
is really irritation to themucosa.
<Julius> how about Diflucan for the harder case
<vlady> brb
<Julius> I have never used it but now have samples
<drjim> Yes seems to be very popular with obs now
<Tom> Diflucan is becoming really popular, some current studies show that
mycostatin is only 45% effective, and that diflucan is about 85% effective.
<Tom> The problem with this whole area is "Diagnosis".
<Julius> is it safe to use
<Julius> What do you mean tom
<shemesh> difficult to culture nipples
<Tom> Many women complain of nipple pain, generally associated with oral
candidiasis in their infant,  so the next step is to assume that the nipple
is infected,  we call it deep ductile candidiasis.
<drjim> But is Diflucan ok with the baby ?
<Tom> But the problem is that many women even after 2 weeks of difulcan
still have pain.
<shemesh> brb
<Julius> I saw this question on pedtalk
<Julius> Does anybody out there in cyberspace know anything about pregnant
and/or
<Julius> lactating women taking gingseng and its effect on the fetus and/or
the
<Julius> nursing infant? The mother was hyperthyroid and on
propylthiouracil in
<Julius> addition. Any help would be appreciated.
<Julius> Dan Nussbaum
<Tom> Is it safe,  yes,  of the azole family Diflucan is by far the safest
of the group.  Several studies have found it to induce liver enzymes, but
all these patients had AIDS and were being treated with other products.
its cleared by the
FDA down to 6 months of age.
<drjim> Thank you Tom now is the ban on Flagyl still there ?
<shemesh> yes I would also like to know about Flagyl
<Tom> Yes, buts it rather silly.  There
<Tom> has never been a case of mutigenicity in humans ever reported. We use
it in our NICU every day.
<DrSue> Diflucan, per Cheston Berlin Chair of AAP Drug Committee is OK for
breast feeding Mom's and babies.
<drjim> Please elaborate the Flagyl issue
<Tom> Diflucan however does not pass into milk very well so the infant
needs therapy as well.
<DrSue> Flagyl will also be on list of AAP Drug List for Lactating Mothers
to be published in 1999. This list is published every 5 years.
<Julius> Dilucan is very expensive compared to nystatin and gentian violet
<Tom> As for flagyl,  it was reported to be mutagenic many many years ago
in animal models,  it has never been found to be so in humans.
<drjim> Will it be on the short or long list  bad or good ?
<DrSue> Kay Hoover - Lactation Consultant has just joined us by telephone.
She continues to have difficulty getting connected online.
<Julius> I find the druglists confusing and not straight forward sometimes
<Julius> Dodo
<Tom> Diflucan is awfully expensive,  I generally suggest that the mom take
diflucan and the infant continue to use nystatin unless the yeast is
totally refractory.
<DrSue> Three drugs to be approved, per Kay Hoover conversation with Chet
Berlin are diflucon, flagyl, and ciprofloxin.
<Tom> I'm still a little concerned about cipro.  One good reported case of
c.dificle reported in a mom who took 6 days worth, and the infant had
severe bloody diarrhea.
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<Julius> What other antibiotics are any isue if any
<Julius> Please introduce yourself and where you are from shemesh
<shemesh> Wow I feel like alice in wonderland
<drjim> How about acyclovir in mom with HSV-2 (Not the parturition issue)
but later during lactation if she is having an outbreak ?
<DrSue> Thanks Tom. We will refer the cipro case to Cheston Berlin. Are
there any more specifics about the case report?
<Tom> Most antibiotics are really quite safe to use, particulary the pens,
cephs, vancomycin, erythromycins, etc.
<Tom> As for more specifics on cipro, you'd have to get the case study, I
can give you the reference if you like.
<Julius> it seemsthe list of drugs not to use is quite small
<DrSue> Please give us the reference.
<Julius> How about percodan and codeine?
<Tom> harmon, T. et.al., j. ped. surg. 27:744, 1992.
<DrSue> Acyclovir is used to treat infants with herpes; it should be safe
for the lactating mother and babe.
<Tom> We don'
<DrSue> Thanks Tom. Kay Hoover says that she knows you. She says hello!!
<Julius> Why?
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<Julius> Please introduce yourself and where you are from dovka
<Julius> shalom Dovka
<dovka> where are you from douka?
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<Tom> Sorry, we don't really know much about the true levels of percodan
and codeine, but they've been used for years, and largely without problems,
 Just remember to be careful in infants with GI problems, or neonatal apnea.
<drjim> god point
<dovka> I am here!!!
<Tom> Hi to Kay Hoover.
<drjim> Sorry ....Good
<Julius> Maternal cold medications
<MikeW> Goodnight, and thanks.  
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<Julius> Thansk for coming Mike
<Tom> Wow, julius, you ask the really hard ones.
<Tom> Cold meds contain the typical antihistamines and sympathomimetics in
general.  Most don
<Julius> I get these questiosn almost every week especially this time of year
<Tom> Most dont really cause problems, other than sedation.  Again watch
for apnea.
<drjim> Now for the Predisone issue ?? any brief generalizations Tom ?
<DrSue> Chlortimazole is not made as an infant preparation re: oral prep
for thrush. Can crush and mix with glycerin and apply topically. Is this
safe??
<Tom> prednisone passes into milk very poorly, doses up to 80mg/day can be
used. But i'd be cautious at that level.
<vlady> What to use: El agente menos tóxico. 
<vlady> <Imagen>El que tenga la semidesintegración más breve.
<vlady> <Imagen>Utilizar la dosis eficaz mínima que pueda administrarse con
menos frecuencia.
<dovka> brb
<drjim> How about other Meds mom's with Inflammatory bowel disease are on >>>?
<Tom> I've heard of people using clotrimazole for thrush,  but I'm not a
big advocate of this product.  Studies show that about 15% of users have
elevated liver enzymes,  this is about the highest for any of the azole
family.
<Julius> parlez vous anglais Vlady
<Julius> stop teasing us
<DrSue> Julius - will you send a transcript of this chat session around? If
not, how can one save and  print out?
<vlady> i was trying to translate but you are very fast
<Julius> I am loging it and will send it by request
<Tom> DrJim,  other meds for UC is a big area. Most of the salicylates are
generally safe, since they're poorly absorbed from the GI tract.  You need
to look up each one.
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<Julius> Please introduce yourself and where you are from JP
<Julius> On second thought my logging was off
<DrSue> Dr Sue and Dr Jerry request a transcript. Thank you!
<Julius> anyone else log it
<vlady> most of the common drugs can be used without stoping breastfeeding
<Tom> Yes, but watch the antihypertensives, particulary
<Julius> one of the best discussions and my log was off
<JP> I also request a transcript. I'm a Ped from Cancun, Mexico, my name is
Juan Pedro Sanchez
<Tom> the beta blockers, acebutolol, and atenolol
<drjim> Any other cardiac meds ?
<Tom> There are at least 2-3 reports of severe apnea is infants of mothers
taking beta blockers.
<vlady> choice the less toxic agent, the briefest seidesintegration and use
the minimal working dose that can be administered with the less frecuency
<Tom> If you need a beta blocker, use propranolol,  breastmilk levels
arevery low.
<DrSue> From my Cancun memories, I think that sitting on the beach at
Cancun is a great place to discuss lactation.
<JP> It must be, but never have had the chance
<JP> to discuss that topic on the beach.
<DrSue> What do you mean about "watch out for anti-hypertensives"! Many
eclamptic women are on them post partum. The literature says that Mag
Sulfate is OK with lacation postpartum.
<Tom> Do you guys see a lot of floppy kids from epidurals?
<Tom> I mean the typical beta blockers,  and maybe some of the CCBs
<Julius> never noticed this problem
<dovka> I thought not until I started looking.
<drjim> ca channel blockers ?
<Tom> Mag sulfate is no problem, postnatally, levels in milk are minimal,
poor oral bioavailability.
<dovka> by the way I am shemesh who come back as dovka!
<DrSue> The issue is what else the women gets beside the epidural and/or
the prolongation of labor caused by the epidural placed too soon.
<Tom> Good,  I read that you don't want to use an epidural until 8 cm
<Tom> Or was it 5 cm
<DrSue> Next time we can discuss OB issues for Tom's sake. Pediatricians
don't give epidurals or check women during labor.
<Tom> Gosh, have I run you all off ?
<drjim> getting late in ny need my beauty rest to tackle the yuppies
tomorrow  thank you Dr Tom and Juluis. 
<vlady> almost all drugs are more or less excreted in breast milk  but in
minimal quantities (less than 1-2% of the dose received by the mother) in a
way that finally the ingested dose by the child stays about   0.001 to 0.5%
of the terapeutic dose tolerated by the baby without toxxicity
<DrSue> Any controversies that people feel about lactation and drugs? What
about the creams/lotions that women use on the breast/nipple. Is there any
value to substances other than breast milk as a nipple dressing?
<dovka> dr.tom - your new format (red book) is great. you answered all my
requests. (Toby)
<Tom> Good vlady, I concur..
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<Tom> Hi Toby, glad you like it.  The nipple creams are a sticky wickit
(sp?).  The only one I don't like is the pure vitamin E preps. Dose is
quite high if the pure stuff is used.
<Tom> Everyone seems to like the really pure lanolin stuff.
<DrSue> Agree re: vitamin E. We should not use Vit E topically, at all.
Some nasty
reactions - generalized rash with it's use.
<dovka> how about wheat germ oil?
<Tom> Not only that,  but if the mom uses a small dab 5-8 times daily, the
infant can receive 1000's of mg daily.
<DrSue> Kay Hoover reminds us that there is a new lanolin available which
has pesticide removed. Lanolin can be used for nipple cracks.
<Tom> Yes,  you'd only want to recommend the pure lanolin manufactured for
this purpose.
<Julius> arree there special brands
<LAS> I've had good results with modified lanolin but have heard rare
reports of baby becoming "addicted"
<Julius> what about ginsing?
<Tom> Yes, but I don't know their names.  Addicted,  that's strange.
<DrSue> PureLan, Lansinoh are two preparations Kay is recommending.
<Tom> Ginsing, I've just received a really good pharmacology book on herbals.
<LAS> I guess they get use to the feel, taste, smell or something.
<DrSue> Kay Hoover does not know of addiction to lanolin. What do you mean
by addiction?? Lanolin only if there is a break in the skin surface.
<Julius> las and dovka I am very glad you are here and hope you go to
www.pedschat .org to register and be put on our mailing list
<DrSue> Does anyone have concern re: zinc oxide on breast topically re:
infant ingestion?
<Tom> Wasn't there a study here recently that heavy genseng users had worse
heart attacks or something?
<LAS> More a preference I guess than an addiction.
<Tom> Zinc Oxide orally is probably a poor choice,  I don't really know if
its absorbed, but pure oils are better.
<Tom> Do you peds use cortisone on the nipple ?
<Tom> If so, which brand ?
<vlady> Ginseng
<DrSue> Cortisone topically for eczema of nipple is probably OK. Must wash
off prior to nursing and re-apply after nursing.
<vlady> only hind milk or lanolin for sore nipples nothing else
<dovka> vitamin A+D is big here - I am leary of fat sol vits
<DrSue> We generally agree re: milk/lanolin and/or air as noted earlier in
chat.
<vlady> and air yes
<vlady> if you need sun..we have here lots of it
<Tom> Good dovka,  fat soluble vits can be hazardous, particularly in a
young liver.
<dovka> saline soaks are great too
<DrSue> Tom - what is really in A&D ointment? We wonder whether or not
there is really Vit A or D in the ointment.
<Julius> great question sue
<Tom> vitamin a and D does have these vitamins, if you wait a minute, I'll
tell you how much.
<DrSue> Kay Hoover reports that in her 27 year old jar of A&D ointment, the
label says Vit A and Vit D in petroleum jelly. Thanks to Kay for doing the
sensible thing - reading the label!
<Julius> just to let you know becuase i din't log the session in MIRC i do
have it captured in Word 7 for windows 95 so you will need this when i send
it to you
<vlady> use them in diaper rash....that's all
<Tom> Thats weird, looked up AandD and the book doesn't list the exact amount.
<Julius> I started using silvadene foir severe burn diaper rashes with
great results
<DrSue> We have Word - please send to our address at
[log in to unmask] Thank you!
<vlady> copy it from word7 and paste in wordpad and save as txt
<Julius> I know it sue and will send everyopne including tom a copy 
<Tom> Julius, are you speaking of candida-like diaper rash?
<Julius> it is word 7 for win 95 remeber
<vlady> what is the price difference betwen silvadene and common ointments?
<Julius> no a diaper rash that is excoriated and bleeding and almost like a
burn
<vlady> in costs?
<DrSue> Agree - why do we have to increase the price of substances used for
common problems?
<Julius> you would be shocked sivadene is cheep
<Tom> Sounds interesting,  do you add cortisone ?
<Julius> I live in HMO heaven
<DrSue> How does silvadene on the backside impact on lactation??
<Julius> no cortisoen just silvadene
<Tom> HMO heaven,  is it burning and hot there. ?
<Julius> not really threw in a tidbit since you discussed diaper rash
<vlady> no impact on lactation, only a happy baby
<vlady> ready to feed
<Julius> For the last 20 years
<DrSue> Seems like the energy level is dropping as we approach 60 minute
chat time.
<Julius> I'd like to thank everyone for coming 
<Julius> next week
<Julius> we will discuss criteria for baby friendly hospital
<DrSue> Enjoyed the chat. Special thanks to Tom and our Israeli and Mexican
friends.
<Julius> I'd like sue to lead discussion
<Tom> Good bye and thanks for the invitation.
<vlady> cortisone when you have z baby with seborrheic dermatitis
<Julius> yes this was truely an educational session
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<DrSue> We will arrange for Kay Hoover to lead and/or take part in the
discussion. She has more expertise than Dr. Sue.
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<Julius> great I hope we get more nurses and others for Monday night
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<Julius> it was a real treat having tom
<DrSue> Kay Hoover suggests Mollie Pessel to add to next week's discussion.
Mollie
is at Evergreen Hospital in Evergreen Washington. Apparently this is the
only approved baby friendly hospital.
<Julius> Please bring them
<DrSue> We will try to contact her and assist in getting on line!
<Julius> I Am working so hard I can not do everything Luckily I have vlady
to help
* vlady ((((((((((((((((((((((((((((( DrSue
))))))))))))))))))))))))))))))))))) Bienvenido a #Pediatrics !!!!!
<Julius> I would appreciate it if you would be a leader of the monday night
discussions
<Julius> I could help advertise but I need someone to lead and think of topics
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<Julius> Please introduce yourself and where you are from BGates
<Julius> o brother it is peter
<DrSue> This is Dr Jerry. I will discuss with Dr. Sue re: leading discussions.
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<Julius> It owuld be great she seems very passionate about the subject
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<Julius> Please introduce yourself and where you are from Andy
<Julius> I'd love to see the Monday night sessions become a great regular
education forum
<Julius> Hi any a little late
<DrSue> Sorry to see that Bill Gates has left our chat re: lactation. You
are right. Sue is passionate re: lactation. However,the topic may have a
limited interest. Perhaps one time per month might be a better frequency.
<Julius> Don't forget wednesday vlady
<Andy> Yes. Sorry about that. I just able to connect to the server
<Julius> Bill gates is Andy from Vancouever our favorite neonatologist
<vlady> nos vemos el miercoles amigos
<Andy> :
 vlady saluda a Andy con un Hola amistoso y le da la Bienvenida a Pedschat!
 I hope you all enjoyed this session

Julius Edlavitch MD  International Pediatric Chat  www.pedschat.org