Ginger-16 yo Poochon (Bichon Poodle mix)

Hi all,
I know I haven't been around since I lost my girl a little over 4 years ago. It looks like we are headed down this path again. I am beside myself at what to do. She is 16 years old and we have been having skin problems for a couple of years we have tried a lot to get it under control. Each step has helped but not quite hit the mark. I know skin problems are a part of Cushings. We fought it for about 3 1/2 years with my girl before she passed. We just don't know what to do with Ginger. She is harder to medicate than Shasta was. I will post a second post with tests I have right now. Really would like experiences and more information on Lysodren protocol. Thanks everyone.

Here are her overall particulars
Ginger is 16 years old
as the title says she is a Poochon (Bichon Frise & Poodle mix) she doesn't like being called a Bichipoo her ears drop backwards but keeps them forward with Poochon
She is almost 14 pounds
She takes 500 mg Quercitin daily
2 drops of CBD oil
Back on Gabapentin 100 mg daily

We had her on Apoquel but took her off (after being on it we noticed more growths than she had before. mostly wart like)
She is on Darwin's Pet food which is raw but has directions for lightly cooking it which we do
She has started to refuse her food with the meds and we are really struggling with that

Patient Info: Hospital: Name: Ginger Species:Dog Hawks Prairie Veterinary Hospital Record No: 32988 Breed: Poodle, Miniature 8919 Martin Way East Owner: Livermore, Ann Age: 16Y Lacey, WA 98516 Doctor: Kim Martin, DVM Sex: S
Accession No. Doctor Owner Patient Name POBC52006567 Kim Martin, DVM Livermore, Ann Ginger
Test Results Adult ReferenceRange L H Normal
Superchem Date given: 02-08-19 T8:49a
Total Protein 7.1 5.0-7.4 g/dL
Albumin 4.1 2.7-4.4 g/dL
Globulin 3.0 1.6-3.6 g/dL
A/G Ratio 1.4 0.8-2.0
AST (SGOT) 31 15-66 IU/L
ALT (SGPT) 109 12-118 IU/L
Alk Phosphatase 649 5-131 IU/L HIGH
GGT 12 1-12 IU/L
Total Bilirubin 0.1 0.1-0.3 mg/dL
BUN 49 6-31 mg/dL HIGH
Creatinine 1.2 0.5-1.6 mg/dL
BUN/Creatinine Ratio 41 4-27 HIGH
Phosphorus 4.5 2.5-6.0 mg/dL
Glucose 87 70-138 mg/dL
Calcium 10.6 8.9-11.4 mg/dL
Magnesium 2.5 1.5-2.5 mEq/L
Sodium 145 139-154 mEq/L
Potassium 4.8 3.6-5.5 mEq/L
NA/K Ratio 30 27-38
Chloride 108 102-120 mEq/L
Cholesterol 428 92-324 mg/dL HIGH
Triglyceride 827 29-291 mg/dL HIGH
Amylase 696 290-1125 IU/L
PrecisionPSL 144 24-140 U/L HIGH
In dogs with appropriate clinical signs, this mildly elevated PrecisionPSL result is equivocal for a diagnosis of pancreatitis. In dogs without clinical signs of pancreatitis, a mild PrescisionPSL elevation is an insignificant finding.
CPK 102 59-895 IU/L
Comment(s)
Page: 2
Accession No. Doctor Owner Patient Name POBC52006567 Kim Martin, DVM Livermore, Ann Ginger
Test Results Adult ReferenceRange L H Normal
Hemolysis 3+, , Lipemia 2+ No significant interference.
Complete Blood Count Date given: 02-08-19 T8:49a
WBC 8.6 4.0-15.5 10^3/mL
RBC 7.0 4.8-9.3 10^6/mL
HGB 16.5 12.1-20.3 g/dL
HCT 48 36-60 %
MCV 68 58-79 fL
MCH 23.7 19-28 pg
MCHC 35 30-38 g/dL
Platelet Count 662 170-400 10^3/mL HIGH
Platelet Estimate Increased
Neutrophils 68 60-77 %
Bands 0 0-3 %
Lymphocytes 25 12-30 %
Monocytes 5 3-10 %
Eosinophils 2 2-10 %
Basophils 0 0-1 %
Absolute Neutrophils 5848 2060-10600 /mL
Absolute Lymphocytes 2150 690-4500 /mL
Absolute Monocytes 430 0-840 /mL
Absolute Eosinophils 172 0-1200 /mL
Absolute Basophils 0 0-150 /mL
T4 Date given: 02-08-19 T8:49a
T4 <0.5 0.8-3.5 mg/dL
Result Verified The Total T4 result is less than 1.0 mcg/dl. A Free-T4 by equilibrium dialysis may be helpful in supporting the diagnosis of hypothyroidism in patients demonstrating clinical signs compatible with hypothyroidism.Please contact Customer Service for this additional testing.
Urinalysis-Complete Date given: 02-08-19 T8:49a
OTHER
Page: 3
Accession No. Doctor Owner Patient Name POBC52006567 Kim Martin, DVM Livermore, Ann Ginger
Test Results Adult ReferenceRange L H Normal
Testing which requires urine has been requested on this patient; however, no urine was received. Please submit a urine sample, WITHIN 30 DAYS, on a new test request form including this reference number and order unit code 3004 so we may complete the testing.Please call Customer Service with any questions.
Cortisol Serial 3 DEX Date given: 02-08-19 T8:49a
Time 1 7
Time 2 Post1
Time 3 Post2
CORTISOL SAMPLE 1 7.4 1.0-5.0 mg/dL HIGH
CORTISOL SAMPLE 2 DEX 0.7 0.0-1.4 mg/dL
CORTISOL SAMPLE 3 DEX 0.6 0.0-1.4 mg/dL
INTERPRETATION OF THE DEXAMETHASONE SUPPRESSION TESTS: * Low-dose dexamethasone suppression test: Normal: Cortisol level less than 1.4 ug/dl 8hrs post-dex. Hyperadrenocorticism: Cortisol level greater than 1.4 ug/dl 8hrs post-dex. ... If the 8hr post dex. cortisol level is greater than 1.4 ug/dl, the following can be used to differentiate pituitary dependent hyperadrenocorticism (PDH) from an adrenal tumor: 1. Cortisol level less than 1.4 ug/dl 4hrs post-dex is consistent with PDH. 2. Cortisol level less than half the baseline level at either 4 or 8 hours post-dex is consistent with PDH. (Samples taken at 2 or 6hrs are interpreted the same way as a 4hr sample) ... If neither of these criteria is met, further testing is needed to differentiate PDH from adrenal tumor Cushings. ... NOTE: Approx. 5% of dogs with PDH have normal results. False positives may occur with stress/nonadrenal illness. . ************************************************** ********** High-dose dexamethasone suppression test: Use this test after hyperadrenocorticism has been diagnosed. PDH or AT: Cortisol level suppressed by less than 50% 8hrs post-dex. PDH ONLY: Cortisol level suppressed by > 50% 8hrs post-dex.

Patient Info: Hospital: Name: Ginger Species:Dog Hawks Prairie Veterinary Hospital Record No: 32988 Breed: Poodle, Miniature 8919 Martin Way East Owner: Livermore, Ann Age: 16Y Lacey, WA 98516 Doctor: Kim Martin, DVM Sex: S
Accession No. Doctor Owner Patient Name SEBC32130417 Kim Martin, DVM Livermore, Ann Ginger
Test Results Adult ReferenceRange L H Normal
Superchem Date given: 03-17-20 T8:31a
Total Protein 6.6 5.0-7.4 g/dL
Albumin 3.7 2.7-4.4 g/dL
Globulin 2.9 1.6-3.6 g/dL
A/G Ratio 1.3 0.8-2.0
AST (SGOT) 37 15-66 IU/L
ALT (SGPT) 144 12-118 IU/L HIGH
Alk Phosphatase 410 5-131 IU/L HIGH
GGT 8 1-12 IU/L
Total Bilirubin 0.1 0.1-0.3 mg/dL
BUN 56 6-31 mg/dL HIGH
Creatinine 1.1 0.5-1.6 mg/dL
BUN/Creatinine Ratio 51 4-27 HIGH
Phosphorus 6.4 2.5-6.0 mg/dL HIGH
Glucose 94 70-138 mg/dL
Calcium 11.2 8.9-11.4 mg/dL
Magnesium 2.1 1.5-2.5 mEq/L
Sodium 147 139-154 mEq/L
Potassium 5.1 3.6-5.5 mEq/L
NA/K Ratio 29 27-38
Chloride 105 102-120 mEq/L
Cholesterol 387 92-324 mg/dL HIGH
Triglyceride 488 29-291 mg/dL HIGH
Amylase 797 290-1125 IU/L
PrecisionPSL 138 24-140 U/L
Pancreatitis is unlikely, but a normal PrecisionPSL result does not completely exclude pancreatitis as a cause for gastrointestinal signs.
CPK 993 59-895 IU/L HIGH
Comment(s)
Page: 2
Accession No. Doctor Owner Patient Name SEBC32130417 Kim Martin, DVM Livermore, Ann Ginger
Test Results Adult ReferenceRange L H Normal
Hemolysis 2+, , Lipemia 2+ No significant interference.
Complete Blood Count Date given: 03-17-20 T8:31a
WBC 10.7 4.0-15.5 10^3/mL
RBC 7.0 4.8-9.3 10^6/mL
HGB 17.0 12.1-20.3 g/dL
HCT 50 36-60 %
MCV 72 58-79 fL
MCH 24.2 19-28 pg
MCHC 34 30-38 g/dL
Platelet Count 626 170-400 10^3/mL HIGH
Platelet Estimate Increased
Neutrophils 79 60-77 % HIGH
Bands 0 0-3 %
Lymphocytes 13 12-30 %
Monocytes 4 3-10 %
Eosinophils 4 2-10 %
Basophils 0 0-1 %
Absolute Neutrophils 8453 2060-10600 /mL
Absolute Lymphocytes 1391 690-4500 /mL
Absolute Monocytes 428 0-840 /mL
Absolute Eosinophils 428 0-1200 /mL
Absolute Basophils 0 0-150 /mL
T4 Date given: 03-17-20 T8:31a
T4 0.8 0.8-3.5 mg/dL
The Total T4 result is less than 1.0 mcg/dl. A Free-T4 by equilibrium dialysis may be helpful in supporting the diagnosis of hypothyroidism in patients demonstrating clinical signs compatible with hypothyroidism.Please contact Customer Service for this additional testing.

Canine - Bichon Frise X
Id:
Female Spayed
Owner:
Breed:
379649
Name Livermore, Ann 'Ginger'
Age:
Livermore, Ann 'Ginger'
Gender:
16 years
Patient
Report Date: Tuesday, May 19, 2020
Phone: 253.474.0791 Email: ellie.nuth@bluepearlvet.com 5608 S Durango Street , Tacoma, WA Ellie Nuth DVM, DACVR BPVP WA TACOMA
Requesting doctor direct contact information if the radiologist needs to contact you: Mountain View Vet Hosp
History (2000 max character count) : Cushing's screening
Exam Type: Abdomen
Patient Clinical History
Findings: Abdominal study. The liver was overall moderately enlarged with blunted caudoventral lobar margins, exhibited a smooth capsular surface, diffusely hyperechoic background parenchyma, and contained a few scattered small rounded well-defined hyperechoic nodules up to 0.83 centimeter in diameter. The gallbladder had normal wall thickness and contained a small amount of mobile settling echogenic content. No intrahepatic or common bile duct distention was identified. No hepatic lymphadenopathy was identified. There were a few well-defined strongly hyperechoic rounded nodules present along the mesenteric border of the spleen. Both kidneys exhibit slightly speckled hyperechoic cortices (more echogenic than splenic parenchyma), a few small (0.3 centimeters) thin-walled through transmitting cortical cysts, adequate corticomedullary definition, a large amount of pinpoint speckled medullary mineralization, and mild pyelectasia measuring 0.22 centimeters in the transverse plane on the left and 0.14 centimeter in the right. Both adrenal glands were moderately enlarged for this patient's size with rounded polar margins, more prominent on the left. The left adrenal gland measured 0.70 cm in ventral dorsal thickness caudally and 0.91 centimeters cranially. The right adrenal gland measured 0.58 centimeters in thickness caudally. In the caudal aspect of the bladder, arising from the dorsal trigone wall there was a moderately broad-based medium echogenic nodule which measured 0.54 cm ventral dorsal x 0.48 cm craniocaudal x 0.82 cm mediolateral. No significant amount of vascularity able to be detected in this structure via color Doppler interrogation, but this had limited effectiveness due to motion artifact. Unable to evaluate the rest of the caudal urinary bladder and proximal urethra caudal to this site due to shadowing from the pelvic canal. Remainder of the urinary bladder walls were uniform and exhibited appropriate thickness for bladder size (somewhat small). The pancreas was unremarkable. There was a normal moderate amount of gas in the stomach and small intestines, and gas with semisolid feces in the colon. The walls of the gastrointestinal tract were normal in thickness and had normal distinct layering throughout. No gastrointestinal obstructive pattern or abnormal luminal content, masses/ulcers or other focal GI lesions identified. No abdominal masses, lymphadenopathy, nor free effusion identified.
Assessment:
1. Bilateral adrenomegaly is supportive of clinical suspicion of pituitary dependent Cushing's disease causing adrenal hyperplasia.
2. Diffuse hyperechoic hepatomegaly with few small hyperechoic nodules is most suspicious for nodular regeneration/hyperplasia and steroid or other vacuolar hepatopathy (presumably secondary to Cushing's but additional consideration may be given to other reactive hepatopathy or chronic primary hepatopathy such as chronic toxic insult or hepatitis with hyperplasia). No concerning for neoplasia at this time.
3. Hyperechoic splenic nodules most consistent with incidental myelolipomas.
4. Bilateral nephrocalcinosis/medullary mineralization and mild degenerative change. Small left renal cortical cyst. Mild bilateral renal pyelectasia likely secondary to physiologic diuresis and PU/PD.
5. Singular caudodorsally located urinary bladder trigone mural nodule has characteristics most concerning for early/emerging neoplasia,

Report of Imaging Findings
Referring Practice Tacoma Washington BPVP WA TACOMA
Tuesday, May 19, 2020 US (Ultrasound) Imaging Details
Report created through Asteris Keystone Teleconsultation Page 1 of 6
less likely inflammatory polyp or benign change.

Recommendations: ‡ Adrenal function testing for Cushing;s disease is indicated. ‡ Continue to monitor renal function. ‡ Consider additional testing to workup urinary bladder mural nodule including traumatic catheterization or genetic screening for neoplastic markers (BRAF test). __________________________________________________ _______________________________ Thank you for this referral. I welcome any feedback or follow-up on this case. If you have any questions or would like to discuss this case, please don't hesitate to contact me at ellie.nuth@bluepearlvet.com or (253)474-0791.


I can provide ultrasound images if it would help.

Welcome back Kim!

Welcome, but I am sorry you have need to be here again. We never want to start this journey again but these dogs just seem to know who they can count on for the best care.

Ginger is absolutely adorable! Had I been asked, I would have said she was a Pom/Pom mix! I would have never guess Bichon and Poodle. What a lovely mix! I have to say I laughed at loud at this comment - "...she doesn't like being called a Bichipoo her ears drop backwards but keeps them forward with Poochon". :D:D:D I think I would be on the same wave link tho I have been called a name similar to "Bichipoo". In fact, I am going to try to remember that one for future use. :D:o

While some of her lab results are seen with Cushing's the number aren't what we usually see with the liver enzymes. ALP is often in the 1000's. Ginger's is mildly elevated in comparison. Something to keep in mind - in some studies with humans, CBD oil has caused changes in liver enzymes, even liver damage. This product is not regulated so unless we make our own OR purchase from an individual we trust we can never be sure exactly what is in the oil. Just food for thought. What concerns me most are the kidneys. The PHOS, CPK, and BUN elevations along with the finding on the ultrasound would cause me to want to focus on the kidneys first and foremost to rule out any thing with them that could skew the Cushing's tests. A tumor on any other organ can cause the cortisol to rise naturally and skew the tests to return a false-positive. So in your shoes I wouldn't waste money on tests for Cushing's just yet but rather have an indepth check of the kidneys. Remember - Cushing's is a very slowly progressing condition so there is rarely need to rush into treatment. We want to be as sure as we possibly can that our baby does indeed have Cushing's and not something that could cause elevated cortisol like a tumor or other illness before we start these powerful treatments.

As for Lysodren, it is my personal drug of choice for treating Cushing's. Lyso is given in two phases - the load, or induction, phase in which the drug is given twice a day until signs are seen that the load has been achieved. Then an ACTH is give to be sure the cortisol is in the desired range. If the numbers come back indicating the load has been achieved then the maintenance phase begins. During this phase the Lyso is given 2-4 times a week usually a the same dose used for the load, just spread out over a week VS daily. The typical dose is 50mg/kg/daily divided AM and PM for the load then the same formula divided into 2-4 doses over a week. So if she loaded on 250mg/day then in maintenance she would take 250mg/week - 125mg/twice a week, 62.5mg/4x a week, etc. Since Lyso only comes in 500mg tablets to get doses that aren't easily divided a compounded form can be used. (If you do need to compound we direct you to some reliable pharmacies for this). Here is a link from the Helpful Resource section on Lysodren tips:

https://www.k9cushings.com/forum/sho...d-related-tips

Again, welcome back! I am sure others will be along soon to chat with you as well.
Hugs,
Leslie

My profile pic is from my pup who passed away 4 years ago. She was all Pom. I started an album of Ginger (the link is below).

Ginger has been stumping us for a few years. She was licking herself raw. First it was only her paws then her legs then pretty much all over. We have tried so much to alleviate this. Each attempt has gotten some results but nothing seemed to completely work. So we have just kept on troubleshooting. About a year ago we started seeing scavenging which made us think she needed to be tested, so we had the bloodwork done with a Low dose Dex test which came back negative. We were like great. Last year we also had a raging yeast problem. We finally got that under control. Then she started the licking behavior again. We had been using Apoquel off and on when the licking was the worst. The licking got worse again Sept/Oct. She otherwise seemed fine. We decided to stick with the Apoquel since it seemed to work, although we didn't really want to. Then in January it seemed the yeast came back in a bad way. We went to a different vet. This vet has been touted as being one who pioneered alternative vet practices. He is the one who had us change food and suggested the CBD. We got it from him and our closer holistic vet also said the same brand, so I am pretty confident it is a reliable product. Thanks for the heads up it can cause liver problems in humans. We went with the CBD because we wanted to get her off Gabapentin. Which we did take her off of for several months. After making these changes the bloodwork had some different results. I don't know how much liver values can change which is one of the most dramatic changes. She has also had problems with tooth reabsorption. She is also presenting with more of the classic Cushing's symptoms. Pot-Belly, increased thirst, scavenging behavior, and hair thinning on the trunk, and hind quarter weakness. She only has 9 teeth left due to being pulled or reabsorbed. She also has white dog shaking syndrome. (sorry for the wall of text, my thoughts are a bit random at the moment and I don't seem to be able to organize them)

Thank you for pointing out the kidney issues Leslie. We are waiting to hear from her primary Western vet about either traumatic catherization or Braf testing. Do you have any other suggestions as to what to do to check into possible kidney issues. I had also forgotten until you mentioned it about other things causing false positives (in her case the bladder nodule).

On to more positive fun things here are some pics of her.
https://www.k9cushings.com/forum/album.php?albumid=1282

Thanks again,
Angela

HI, not really an expert on Cushings but I do have a toy poodle diagnosed March 2019 with Transitional Cell Carcinoma. Given Ginger’s age, etc. I would have your vet order a Cadet BRAF Mutation test kit from Sentinel Biomedical. You collect urine over a day or two, put it in their container and Fedex it to them in the envelope they include. Results come back in a couple of days. It is very accurate, almost never a false positive and it’s much easier on these senior dogs than a traumatic catherization. I read about the test online. My vet hadn’t heard of it but he ordered the kit and it was simple to do and noninvasive. We were fortunate to catch Angel’s TCC early. And, also it isn’t in the trigone area. She has been on chemotherapy now since April 2019 and you never know she had cancer. We were very fortunate. Having some other issues lately but unrelated to the cancer. (Just got her home from hospital after bout of gastroenteritis) I had just had Angel in for a lipoma removal and we really didn’t want to put her through another procedure with anesthetic at her age. Her urinalysis had come back with elevated proteins and suspicious transitional cells. At that point we couldn’t see more than just a little thickening in the bladder wall On ultrasound which might have been inflammation however the suspicious transitional cells and protein got us #1 checking and treating her blood pressure which was elevated and #2 we found out early on that she did have bladder cancer. Or if there is an oncology or Internal Med. practice they might have the test kits. Maybe down the road they might feel a catherization is necessary but we have not had to do one and the BRAF test was totally noninvasive. Best of luck with Ginger, Claire

Thanks for the info on the Braf test Claire. I don't know if we would opt for chemotherapy. Ginger seems very sensitive to almost everything. We just had an ultrasound done and there was a nodule in her bladder which is what is prompting further testing about it.

For a while I was thinking Ginger might have atypical Cushing's. Now I'm not so sure. Now I don't feel like I know anything about any of it. I am at such a loss as to what to do next.
Angela

Hi ANGELA, I don't know where I got "Kim" from! :o My apologies. Aged minds do weird things is all I can think of! That aged mind thing also applies to the profile pic.....I used to foster for Small Paws, a Bichon rescue, and had several Bichon/Poodle mixes so I know full well what they look like. :rolleyes: And Ginger is adorable!

As for other testing, the test Clair mentioned is one and the SDMA is another. The SDMA is a fairly new test and is done only by the IDEXX lab. This test tells us much sooner if the kidney function is impaired. Before this test we had to rely on CREA, BUN and other kidney values on the labs but by the time they were showing abnormal the organs has lost something like 75% of function. Not all vets are aware of the SDMA test yet so don't be surprised if Ginger's vet doesn't. The catheterization testing mentioned on the US is another. Based on the comments on the US they too are considering TCC a possibility.

The continuing allergy signs aren't typically seen in an untreated cush pup. The elevated cortisol in Cushing's usually acts as a sort of treatment just as a steroidal medication like prednisone for allergies would act. It is when the cortisol is lowered back to more normal levels with treatment that we see inflammatory conditions like allergies and arthritis come into play. Prior to treatment the cortisol was controlling those conditions. But the signs you mention are certainly associated with Cushing's.

Just fyi - here is the product insert for Apoquel that talks about side effects like certain skin issues and neoplasia that might apply to Ginger:
https://www.zoetisus.com/products/do..._pi_030116.pdf

As for the Shaker Syndrome, treatment for this condition is often prednisone so I would think the elevated cortisol found in untreated Cushing's would also be sort of "treating" this condition and that it would worsen if the cortisol were lowered. But I could be wrong. Like I said, the signs you are seeing are associated with Cushing's. But those signs are shared with so many other conditions too. I would still be focusing on the kidneys first then go from there in your shoes.

Hugs,
Leslie

Hello Angela,
Of course you have to do what you feel is best for your baby. I did see some similarities in our girls though. Angel is 15 as best we can determine. She has an abnormal liver, missing the left lobe and she reacts in very strange ways to many drugs and medications. Galliprant and Apoquel, both which are not supposed to effect the liver and kidneys so much sent her liver enzymes to the moon. We have to be very very careful because we never know how she will handle a new drug. Sometimes the liver enzymes go sky high but there are no actual clinical symptoms. There have also been issues with the bile duct/gall bladder. Her kidneys are definitely aging but still sneak into the ‘normal’ range. She handled chemo well which is another story. Right now since the gastroenteritis we are giving her a drug holiday where she’s off pretty much everything for a couple of days including blood pressure meds. I actually saw a number of similarities in Ginger’s ultrasound and Angel’s.

The reason I would recommend the BRAF is so you know what to expect if it is TCC. It is often found in the trigone area of the bladder and it can result in a serious emergency if the ureters or urethra become blocked and urine cannot pass. IF it turned out to be TCC at least you have an idea as to how it might skew her other test results and if it is something you would want to explore treating. It’s not a terribly expensive test and completely noninvasive. I just had to take a little dish and collect some urine until I had the necessary amount to send. I decided to try and treat it since at that point since we caught it early.

Because so many drugs are metabolized or work thru the liver it can be very tricky managing these dogs and never knowing how they will react to a seemingly innocuous drug. One eye drop of neopolydex per day was enough to keep her liver enzymes elevated. Steroids will send them upwards. So she is definitely complicated as we must always consider how a drug of choice might affect her. Overall Angel has done well and we manage things as they come up but she is an old gal and treatment becomes more complicated. She is also a very picky eater which doesn’t help matters.

I’m sure you will get lots of support in the Cushings department. I feel more experienced in kidney failure, liver, TCC and heart failure issues. I do have a Bichon who was recently diagnosed with Cushings and had a little poodle some years ago who underwent adrenalectomy. And I sure understand the stress and emotional ups and downs of loving our babies so much and wanting to do the best for them. Thankfully there is wonderful support and information here!!
Best,
Claire