CANINE PEDIATRICS
WHELPING
AND POST-NATAL INSTRUCTIONS
The following instructions will aid you in whelping your bitch and in safeguarding the lives of the litter in their crucial first four weeks of life. Should you have any other questions or need assistance at any time, please call the number above.
Taking
care of your pregnant dog
Congratulations!
Your dog is about to become a mother. Here are some things to keep in mind
while
caring for your pregnant dog.
Before
delivery
Your
dog may require regular deworming, heartworm preventives, and flea control while
she is pregnant. Fortunately, many parasite control products can be used during
this critical time. Consult your veterinarian about which one is right for your
pet.
If
your dog is in good physical condition, she will have fewer problems delivering
her pups. Pregnant dogs require regular exercise during pregnancy. Weight
control is important because more delivery problems are seen in overweight dogs.
While weight reduction is probably not advisable during pregnancy, regular
exercise will counteract some of the problems associated with obesity. Going for
a walk, chasing a ball or Frisbee, or doing any exercise your dog is accustomed
to should be safe during pregnancy.
Nutrition
is also important during pregnancy. Ask your veterinarian to recommend a
high-quality, balanced dog food. Don't give your dog vitamin or mineral
supplements, especially calcium supplements, because these could cause a
nutritional imbalance. For the first six weeks of the pregnancy, feed your dog
her normal amount of food. Gradually increase the amount of food during the
final three weeks of the pregnancy so your dog's caloric intake reaches 1.5
times its normal amount. You may need to offer several small meals during the
last three weeks because your dog's uterus enlarges in late pregnancy, reducing
the amount of food her stomach can hold.
During
pregnancy, you may notice vaginal discharges. Occasional mucus discharge is
normal. Even if this discharge is pink-tinged, it is considered normal. If the
discharge contains blood or pus, see your veterinarian immediately because it
could indicate serious pregnancy complications. And be sure to isolate your dog
from other dogs three weeks before to three weeks after delivery to reduce the
possibility of exposure to disease.
A
few weeks before delivery, carefully select a safe and secluded area that is
draft-free and away from household traffic patterns. Provide a box that your dog
can deliver her pup- pies in that is easy to clean. Ideally, the box should have
a rail around it the puppies can move under to help prevent the mother from
accidentally crushing them. Introduce your dog to the box about one week before
the expected delivery date to allow your dog to become acclimated. Line the box
with washable rugs or blankets to give puppies good
During
delivery
The
first stage of labor lasts two to 12 hours. During this stage, the uterus starts
to contract regularly and the cervix dilates. Your dog may show signs of
nesting, nervousness, panting, shivering, loss of appetite, and vomiting.
When
your dog starts experiencing stronger contractions and expels watery fluid, she
is in the second stage of labor. The first puppy will enter your dog's pelvic
canal, stimulating her to push more aggressively. As each puppy is expelled,
your dog will usually break the thin, whitish membrane surrounding the puppy.
Puppies may suffocate if these membranes are not removed from their nostrils
shortly after birth. The normal interval between the delivery of puppies is 30
to 60 minutes. Rest periods are normal, particularly if your dog is delivering a
large litter. During these rest periods, your dog will appear comfortable and
care for the puppies already delivered.
You
may notice a greenish-black uterine discharge, which is normal. If contractions
last longer than one hour or rest periods last longer than four hours, you may
need your veterinarian to step in and help. You should also consult your
veterinarian if your dog has not delivered a puppy an hour and a half after the
watery fluid is expelled. If you see a black, thick discharge and your dog has
not shown signs of labor, call your veterinarian immediately.
During
the third stage of labor, your dog will expel placentas. She may eat the
placentas and chew the umbilical cords free from the puppies. This placental
tissue provides your dog protein and other nutrients, reducing the amount of
food she'll need the first few days after delivery. The placentas usually follow
each pup, but the passing of a placenta may be interrupted when another pup is
delivered. If your dog develops a vaginal discharge that contains pus shortly
after delivery, it may indicate retained placentas, so consult your
veterinarian.
After
delivery
A
vaginal discharge is normal after delivery. You should monitor this discharge
daily. Watch for a decreasing amount of discharge, a change in color from red to
brown, and a change in consistency from watery to mucoid (resembling mucus). It
should never have an odor. Your dog will expel most of the discharge in the
first two weeks, but you may see small amounts over the following four to six
weeks. Blood in the discharge after the first week is abnormal, so if you see
any call your veterinarian.
You
should also examine your dog's mammary glands every day. These glands provide
colostrum and milk for the puppies to ingest. Firm and painful mammary glands
may indicate mastitis, an inflammation of the mammary gland. If you catch this
early, your veterinarian can show you how to apply hot compresses or perform
milk stripping two to four times a day to keep the problem from getting more
serious. In most cases, the puppies should still be able to nurse.
As
for the puppies, have your veterinarian examine them soon after delivery. The
puppies should ingest colostrum within the first 24 hours after birth. Weigh the
puppies every day to document weight gain. The puppies should gain weight daily,
although there may be a short lag in the first day or two after delivery. Weight
loss or the absence of weight gain may mean serious problems, so consult your
veterinarian.
Puppies
cannot regulate their body temperatures, so you must keep them warm for the
first two weeks of
life.
Drafts pose the greatest threat for puppies. You can provide supplemental heat
sources, such as heating pads or heat lamps on low thermostat settings. Just
make sure the puppies can get away from the heat source to avoid becoming too
hot. The puppies should remain with their mother during the first several weeks;
she will feed them, help keep them warm, stimulate them to urinate and defecate,
and teach them appropriate canine interactions.
REPRINTED
FOR EDUCATIONAL PURPOSES
FROM
VETERINARY MEDICINE MAGAZINE OCTOBER 2000
THE
WORLD OF A PUPPY
Puppies arrive into this world
in a care dependent state. The fact that their eyes and ears are sealed reflects
their incompletely developed nervous system. They are born capable of little
spontaneous movement and must be stimulated by the mother's licking to begin
breathing, irregularly at first.
Because of an inability to maintain body heat, puppies must stay close to
their mother and littermates. A puppy will orient itself toward the source of
licking directed at its head and dorsum. This natural rooting reflex encourages
the puppy to turn and push toward any warm object near its head. Since any warm
object(s) would most likely be its mother or littermates, the reflex is
important in establishing the puppy's initial bond with the mother. The reflex
begins to disappear at 4 days.
PHYSICAL
EXAMINATION
Most healthy puppies are first examined by veterinarians at 6 to 8 weeks
of age when they receive their initial vaccines. Puppies younger than 4 weeks of
age should be examined with the mother present to keep them calm. Puppies
younger than 5 weeks should be examined on a warm surface and by an individual
with warm hands. Warm the surface with a warm water heater blanket or use a
small cardboard box lined with blankets containing hot water bottles.
Before handling the puppy, first observe its reaction to the surrounding
environment. Make note of the puppy's general physical condition, mentation,
posture, locomotion, and breathing pattern. Next, record the puppy's weight in
grams or kilograms and obtain vital signs. The normal rectal temperature for
newborn puppies is 96°F to 97°F. After 1 to 2 weeks the rectal temperature
gradually increases until it reaches 100°F by 4 weeks of age. The heart rate
should be rapid and strong; breathing should be regular and unlabored
Body weight is an important parameter in determining the health of very
young puppies. Weight loss or failure to gain weight is one of the first signs
of illness. Having the owner keep an accurate daily record of each puppy's
weight for the first 3 weeks of life and every 2 weeks thereafter is helpful in
detecting a health related problem. Puppies should gain 1 to 1.25 gm/lb.
(2
to 4 gm/day/kg) of expected adult weight daily or double their birth weight
within 2 weeks. For example, to achieve a normal adult weight of 50 pounds, a
puppy should gain 50 to 75 grams of weight daily.
To assess the physical condition of a puppy that is still developing
requires knowledge of normal developmental stages. The physical examination
should be conducted in a systematic manner. Although the examination may be
easier to complete by proceeding from the puppy's head to its tail, it is
advisable to examine and record observations according to various body
systems-digestive, urinary, circulatory, nervous, respiratory, and
musculoskeletal.
Congenital
Defects
In general, the incidence of heart murmurs caused by congenital heart
defects in puppies is extremely low; however, heart defects, along with hearing
problems, are the most likely abnormalities to be noticed at home by the owners
or during the puppy's first routine examination by the veterinarian. Various dog
breeds are known to be afflicted with congenital heart defects while 46
different breeds currently are recognized to have congenital unilateral or
bilateral deafness.
During the first, examination, the head is checked for evidence of
malformations of the skull as well as cleft lip, stenotic nares, cleft palate,
and open fontanelle; brachycephalic dog breeds are predisposed to these
malformations. All puppies should have functional hearing by 6 weeks of age and
older. As the examination proceeds:
·
Open the mouth and look at the mucous membranes.
They should be light pink and moist.
·
Evaluate the condition of the skin, checking for
wounds, state of hydration, and completeness of hair cover. The coat should be
shiny and free of debris. If necessary, the skin examination may include
diagnostic procedures such as exfoliative cytology, bacterial culture and
sensitivity testing, skin scraping, dermatophyte culture, and identification of
external parasites.
·
Inspect the umbilical area carefully for signs of
infection or abdominal wall abnormalities. The cord usually falls off 2 to 3
days after birth.
·
Examine the perineal region and the genitals for
congenital defects or intersex characteristics. The testicles should descend by
4 to 6 weeks of age. If both testes have not descended by 7 to 14 weeks,
cryptorchidism should be suspected. Examine the rectum and anus for signs of
inflammation or congenital defects. Look for any signs of diarrhea,
constipation, or abnormal micturition.
·
Check the limbs and tail to ensure that all appear
normal.
NUTRITION
Puppies should gain 5% to 10% of their birth weights per day if they are
being fed properly. Underfeeding is always preferable to overfeeding, which may
cause obesity and musculoskeletal diseases. It is important to remember that
puppies require twice the fat and protein and more calcium and phosphorus than
that which ordinary cows milk provides. Homemade or commercial milk replacement
formulas are also imperfect substitutes for the canine mother's milk, although
there are some fairly well balanced commercial milk replacer formulas available.
The following methods can be used as a feeding formula for growing puppies:
·
commercial powdered or liquid bitch's milk
substitutes for first 4 to 6 weeks of life, and;
·
one part dry puppy food to three parts milk
replacer or water (two parts canned puppy food to one part milk replacer or
water) that is processed in a blender for 3 weeks of age and older.
The transition from mother's milk to solid food should be a gradual
process beginning at about 3 weeks of age (4 weeks of age for toy breeds);
however, if necessary, supplemental feeding may be started as soon as the puppy
fails to show weight gain.
WEANING
PROCEDURE
Weaning is a stressful time for the lactating mother as well as for the
puppies. Most puppies are weaned at 6 weeks of age, which coincides with the
period of peak milk production in the bitch. The sudden termination of mother's
milk is accepted more readily if the puppies have been prepared beforehand with
the gradual introduction of food labeled as puppy growth food. Inquisitive
puppies are ready at 3 to 4 weeks to be fed canned puppy food or given a gruel
made of commercial dry food blended with water. By 5 weeks, puppies should be
consuming a nutritionally complete and balanced food supplemented by occasional
nursing.
HOUSE
TRAINING
A puppy instinctively will not soil its bed if given alternative areas on
which to relieve itself. During the first 3 weeks of life, the mother licks the
external genitalia every few hours with her tongue to stimulate urination and
defecation and to clean the puppies. She ingests the excreted waste. Once
puppies are old enough to begin eating solid food, they wander a short distance
away from the bed to relieve themselves.
Puppies are not capable of controlling urination or defecation until 8
weeks of age. Before this time, they express their bowels or urinary bladder 15
to 30 minutes after awakening and eating, during intense activity, and before
bedtime. House training for a new puppy usually takes from 2 to 4 weeks and is
accomplished through confinement, a regular schedule of feeding and elimination
breaks, a great deal of praise, and limited to no punishment.
PREVENTIVE
HEALTH SCHEDULE
Parasites
Puppies should be checked for gastrointestinal parasites and dewormed at
3 weeks of age and older. They also require fecal reexaminations and deworming
when they return for their routine vaccinations. Gastrointestinal parasites can
cause serious disorders in puppies, including life threatening anemia, diarrhea,
weakness from hypoglycemia, and weight loss. The most common parasites of
puppies are hookworms, roundworms, whipworms, tapeworms, Giardia, and coccidia.
The method of infection varies with the type of worm, but includes
transplacental transfer, infection via milk while nursing, skin penetration, and
oral ingestion. Treatment includes immediate therapy with appropriate
anthelmintic medications, follow up therapy 2 to 4 weeks later to kill migrating
stages of the parasite, and environmental clean up to prevent reinfection.
Dogs should be checked for worms on a regular basis: at 3 weeks of age; 6
to 8 weeks of age; 10 to 12 weeks of age; 14 to 16 weeks of age; and on an
annual basis (minimum) as adults. The test requires a small sample of fresh
feces, flotation solution (sodium nitrate solution prepared to a specific
gravity of 1.36 works best), and a good microscope. The fecal sample is
suspended in flotation solution, topped with a coverslip, and allowed to stand
undisturbed for 5 to 10 minutes. The coverslip is then placed on a glass slide
and examined for parasite ova. Tapeworm infections are rarely diagnosed by fecal
examinations because the eggs are contained within segments of the tapeworm (proglottids),
which crawl out of the puppy's anus and fall to the ground. Commercially
produced test kits can be obtained to identify parasite ova in feces as well.
Heartworm preventive medication should be started at 6 to 8 weeks of age
in areas where heartworms are endemic. Heartworm infection can be prevented by
administering oral medications to heartworm negative dogs on a regular basis.
Duration of administration will vary depending on the mosquito season in the
particular geographic area. In the southern United States, where the disease is
endemic, prophylactic medication should be given year round.
A puppy is usually started on heartworm prophylaxis using milbemycin
oxime, ivermectin, or diethylcarbamazine. The heartworm preventive product that
contains milbemycin oxime should be administered orally at the recommended
minimal dose level of 0.5 mg/kg of body weight at monthly dosing intervals. The
ivermectin product should be administered orally at the recommended minimum dose
level of 6.6 microg/kg at monthly dosing intervals. Heartworm products that
contain diethylcarbamazine are available for oral administration as a chewable
tablet, standard tablet, and syrup from a variety of manufacturers and should be
given once a day at a dose rate of 6.6 mg/kg (3 mg/lb.). Heartworm preventive
products of any type should be started in heartworm infested areas 1 month
before the beginning of mosquito season and for about 2 months thereafter. Dogs
should be given a heartworm examination annually.
Vaccinations
Puppies are very susceptible to certain infectious diseases, especially
canine distemper, infectious canine hepatitis, parvovirus, parainfluenza,
leptospirosis, bordetellosis, and rabies. Puppies receive antibodies from their
mother via the colostrum, which usually protects them from these diseases for 6
to 8 weeks. Once the puppies lose their maternal antibody protection they are at
high risk of contracting these diseases if exposed to an infected animal. Since
the duration of protection provided by maternal antibodies can vary (the range
is 3 to 20 weeks), it is recommended that puppies be vaccinated on a repeat
basis until 4 months of age. Once the vaccination series is completed, annual
boosters are required to maintain protective antibody levels.
The initial vaccination series consists of one injection of a multivalent
vaccine given at 6 to 8 weeks of age and three boosters given first at 9 to l2
weeks of age and next at 14 to l6 weeks of age. Puppies whose immune status is
uncertain may receive additional injections of multivalent vaccine as early as 2
weeks of age. The rabies injection is given at 3 months of age or older.
Dental
Care
Puppies are diphyodont animals; they produce a generation of deciduous
teeth that are shed and replaced by permanent teeth when the jaw reaches
maturity. Deciduous incisors appear as early as 4 weeks of age. Full dentition
is usually present in a puppy by 8 weeks of age. Shortly after the deciduous
tooth is completely erupted, it starts to undergo an absorptive process
beginning at the root. Under each deciduous tooth root a permanent tooth bud
starts to develop. When the permanent tooth is completed and erupts through the
gingiva, the deciduous tooth is shed. Permanent teeth of large breed dogs erupt
a few days before those in smaller breeds.
Weaning is accomplished at
about 6 weeks of age by separating the mother from her puppies and allowing the
puppies free access to commercial puppy food.
Care
of the mother dog during weaning:
Reduce the mother's food a few
days before the event and give her only a small amount of food on the first day
of weaning. Limiting her food intake will decrease the amount of milk she
produces. It is important to allow the mother free access to water. On the
second and third days of weaning, the mother can be fed one half of the amount
of the nutritionally complete food she was being fed until the last few weeks of
gestation. By the fifth day after weaning the mother should be back to her
normal diet. A mother who is producing large amounts of milk may benefit from
the application of warm compresses to her mammary glands in order to decrease
discomfort during the initial weaning stage.
Weaning
the puppy:
During the changeover to solid
food, puppies can be offered a mixture of a good quality puppy food mixed with
water in a thick gruel. To encourage puppies to eat, the gruel is placed in a
shallow food bowl or is given orally using a dose syringe. (Ask your
veterinarian how to use a dose syringe if you have questions about how to do
so.) You also can encourage puppies to lap the gruel from the shallow bowl by
touching their lips to the food, or you can dip a finger in the gruel and then
place it into the puppy's mouth. Once the puppy is eating the gruel well,
gradually reduce the amount of water in the gruel until the water is omitted.
You can separate your puppy from its mother as soon as it learns to eat and
drink satisfactorily. Most puppies are completely weaned at 5 to 7 weeks of age,
depending on the breed. Early weaning and separation from littermates before 6
weeks of age, however, can cause numerous behavioral problems later in life.
Because of this, complete weaning should not be attempted until your puppies are
at least 6 weeks old and close human contact has been established.
Feeding
the weaned puppy:
The food fed to your puppy
after weaning should be one specifically formulated for growth. Supplementing
the food with meat, table scraps, or other items is not recommended, because it
will likely create a finicky eater, nutritional deficiencies or excesses, or
both. Because the puppy's eating habits are still in the developmental stage, it
is important to feed a good quality growth puppy food at regular intervals until
adulthood and provide fresh water in a clean bowl at all times.
Feeding the weaned puppy
should always be directed to attaining the average growth rate for the
particular breed. Overfeeding is not recommended. Use the stated feeding amount
and schedule on commercial food containers as a convenient guide for determining
the amount of food you should feed to your puppy daily in order to achieve
average growth.
How
to teach good eating habits:
Instead of making food
available to your puppy at all times (free choice feeding), time limited meal
feeding is recommended. At each feeding, give the puppy 20 minutes to eat all
that it wants and then remove the remaining food. From weaning to 6 months of
age (12 months for giant breeds), puppies are best fed at least 3 times a day at
regular intervals.
Initially, your puppy should
be confined to a small box or crate that is large enough for it to lie down in
with its legs extended. Food should be offered on a regular schedule. Every hour
and before bedtime, carry your puppy to the same designated area to relieve
itself. Successful urination or defecation should be rewarded with lavish
praise. To prevent a puppy from defecating or urinating where it shouldn't, food
or large amounts of water should not be left in the crate with the puppy
overnight.
The length of time between
trips outside the box or crate can be extended as the puppy learns to control
its urinary bladder and bowels. The puppy will signal its intent by crying or
sniffing earnestly at the floor when it needs to go out. The area of confinement
should be gradually enlarged as the puppy learns control until it earns the
right to spend the day unconfined. However, even when completely house-trained,
puppies should be confined to small areas during the night to prevent accidents.
Age
Disease
6
weeks Canine
distemper
Infectious
canine hepatitis
Parvovirus
Parainfluenza
Leptospirosis
Bordetellosis
9
weeks Canine
distemper
Infectious
canine hepatitis
Parvovirus
Parainfluenza
Leptospirosis
Bordetellosis
12
weeks Canine
distemper
Infectious
canine hepatitis
Parvovirus
Parainfluenza
Leptospirosis
Bordetellosis
15-16
weeks
Canine distemper
Infectious
canine hepatitis
Parvovirus
Parainfluenza
Leptospirosis
Bordetellosis
Rabies**
Or
draw blood for an Immunity check*
Annually
thereafter
Canine distemper
Infectious
canine hepatitis
Parvovirus
Parainfluenza
Leptospirosis
Rabies
Bordetellosis
*Immunity
check means determining serum antibody titer for canine parvovirus especially in
Rottweilers and Doberman pinschers. Revaccination at 15-16 weeks is
recommended if no immunity check is done.
**Rabies
vaccinations are given annually or triennially, depending on the vaccine used
and local statutes.
BREEDS
OF DOGS PREDISPOSED TO CONGENITAL HEART DEFECTS
Patent ductus arteriosus Poodle*,
Pomeranian, Collie, German shepherd, Shetland sheep dog, Maltese, Keeshond,
English springer spaniel
Subaortic
stenosis
Newfoundland*, boxer, German shepherd, golden retriever, German
shorthaired pointer, rottweiler
Pulmonic
stenosis
Beagle*, English bulldog, Chihuahua, fox terrier, Samoyed, miniature
schnauzer
Vascular
ring anomaly
German shepherd*, Irish setter, Great Dane
Ventricular
septal defect
English bulldog
Tetralogy
of Fallot
Keeshond*
Mitral/tricuspid
valve dysplasia
Labrador retriever, Great Dane, Weimaraner, English bulldog, Chihuahua
*Hereditary
transmission confirmed by breeding trials.
Akita
English bulldog
Pit bull terrier
American
Staffordshire terrier English
setter*
Pointer
Australian
cattle dog* Foxhound
Rhodesian ridgeback
Australian
shepherd* Fox
terrier
Rottweiler
Beagle
German shepherd
Saint Bernard
Border
collie
Great Dane (merle color)
Schnauzer
Boston
terrier
Great Pyrenees
Scottish terrier
Boxer
Ibizan hound
Sealyham terrier
Bull
terrier*
Jack Russell terrier Shetland
sheepdog
Catahoula
leopard dog* Kuvasz*
Shropshire terrier
Cocker
Spaniel*
Maltese
Siberian huskies
Collie
(merle)
Miniature poodle Toy
poodle
Dalmatian
coach dog* Mongrel
Walker American foxhound
Dappled
dachshund Norwegian
dunkerhound
West Highland white terrier*
Doberman
pinscher
Old English sheepdog
Dogo
Argentino* Papillon *HIGH
BREED INCIDENCE
AGE
RELATED DEVELOPMENTAL STAGES
BODY
SYSTEM
AGE
DEVELOPMENTAL STAGES
Eyes
Birth-13 days Eyelids
are closed, but puppies respond to a bright light
with a blink reflex. This
reflex disappears at 21 days, probably due to development of accurate pupil
control.
Palpebral reflex is present at
3 days, becoming adult-like
by 9 days.
5-14
days
Menace reflex is present, but slow. Eyelids separate into upper and lower
lids. Pupillary light responses are present within 24 hours after eyelids
seperate. Reflex lacrimation begins when eyelids separate. Corneal reflex is
present after eyelids separate.
3-4
weeks
Vision should be normal.
Ears
Birth-5 days External ear canals are closed. Hearing is
poor.
10-14
days
External ear canals open (should be completely open by 17 days). For the
first week after the ear canals are completely opened there is an abundance of
desquamated cells and some oil droplets, which is normal as the ear canals
remodel to the external environment.
Teeth
4-6 weeks
Deciduous incisors erupt, followed by deciduous
canines.
4-8
weeks
Deciduous premolars erupt.
Circulatory
Birth-4 weeks Lower
blood pressure, stroke volume, and peripheral
vascular resistance present.
Increased heart rate (>220bpm), cardiac output, and central venous pressure.
Heart rhythm is regular sinus.
Respiratory
Birth-4 weeks
Respiratory rate is 15-35 breaths per minute
Neuromuscular
Birth
Flexor dominance is present at birth, with extensor
dominance starting as early as 1 day. Seal posture reflex can last up to 19 days. Sucking reflex is present, but disappears by 23 days. Anogenital reflex disappears between 23-39 days. Cutaneous pain perception is present, but withdrawal reflex is noticeable at about 7 days. Tonic neck reflexes are present until 3 weeks of age. Puppy can raise head. Righting response is present. Myotactic reflexes are present at birth, but difficult to elicit in newborns. Panniculus reflex is present at birth.
5 days Nystagmus associated with rotatory stimulation appears at the end of the first week. Cross extensor reflex ends between 2-17 days; persistence of this reflex indicates upper motor neuron disease. Direct forelimb support of body weight.
14-16
days
Puppies are crawling. Rear limb support of body weight.
20
days
Puppies can sit and have reasonable control of distal phalanges.
22
days
Puppies are walking normally. Vestibular nystagmus becomes adult-like.
23-40
days
Puppies are climbing and have air righting response.
3-4
weeks
Hemiwalking response, but may not be fully developed in rear limbs until
6 weeks old.
6-8
weeks
Postural reactions are fully developed. Time frames for normal
development are approximate since variances occur in some individuals.
REPRINTED
FOR EDUCATIONAL PURPOSES FROM PERSPECTIVES
JAN/FEB 1995
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