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Cystic Fibrosis

  • The outlook for a child with cystic fibrosis (CF) has never looked better. In the 1950s, few children with cystic fibrosis lived to attend elementary school. Today, advances in research and medical treatments have greatly improved the lives of people with CF; many children with the condition can expect to live into their 40s and beyond.

    • Cystic fibrosis (CF) is a common hereditary (inherited) chronic disease that can affect multiple parts of your child’s body -– most commonly her lungs and digestive system.
       
    • The goals of treatment are to ease severity of your child’s symptoms and slow the progression of the disease.
       
    • At the present time, there is no cure for CF, but with medical and psychosocial support, many children and adolescents with CF can cope well and lead a productive life.

    How Boston Children’s Hospital approaches cystic fibrosis

    The  Cystic Fibrosis Center at Children's is one of the oldest and largest cystic fibrosis centers in the United States. Caring for more than 500 children and adults each year, we provide services ranging from evaluation and diagnosis to treatment and patient education.

    Our center is staffed by an experienced, multidisciplinary team of clinicians, all of whom have specialized training in the care of patients with cystic fibrosis. This approach ensures a thoughtful discussion of every treatment possibility in every case. Your child is in excellent hands with us.

    Cystic Fibrosis: Reviewed by Debra Boyer, MD
    © Children’s Hospital Boston, 2011

    Contact Us

    Boston Children's Hospital
    300 Longwood Avenue
    Farley 4
    Boston MA 02115

     617-355-1900
     fax: 617-730-0373


  • We understand that you may have a lot of questions when your child is diagnosed with cystic fibrosis:

    • Is it painful?
    • Does my child need to be hospitalized?
    • How will it affect my child long-term?
    • What do we do next?

    We’ve tried to provide some answers to those questions in the following pages, and when you meet with our experts, we can explain your child’s condition fully.

     

     

     

     

     

     

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    What is cystic fibrosis?

    Cystic fibrosis (CF) is a common hereditary (inherited) chronic disease that can affect multiple parts of your child’s body -– most commonly her lungs and digestive system. A defective gene causes the body to produce unusually thick, sticky mucus that:

    • clogs the lungs and leads to lung infections
    • obstructs the pancreas and stops natural enzymes from helping the body break down and absorb food

    What does “cystic fibrosis” mean?

    Fibrosis refers to an excessive amount of fibrous connective tissue in an organ. In cystic fibrosis, this build-up leads to cysts forming, most commonly in the lungs and pancreas.

    How does CF affect my child’s respiratory system?

    Normally, mucus is thin and can be easily cleared by the airways. With CF, mucus becomes thickened, sticky and gradually blocks the airways. Eventually, cysts may develop due to this blockage. This can result in:

    • Lung infections
      • These are quite common in children with CF, because bacteria that are normally cleared by the airways remain in the thickened mucus.

      • Many of these infections are chronic (recurring).

      • They are commonly caused either the pseudomonas aeruginosa (PA) or Staphylococcus (staph) bacteria.

    • Problems with the upper respiratory tract

      • About 10 to 20 percent of children with CF have nasal polyps­ — small protrusions of tissue from the lining of the nose — that need to be surgically removed.

      • Children with CF also have a high rate of sinus infections.

    How does CF affect the digestive system?

    1. The gene that has the CF mutation – the CFTR gene – controls the flow of water and certain salts in and out of the body's cells. The mutation means that mucus throughout your child’s body becomes thickened.

    2. The pancreas secretes substances that help digestion. In around 90 percent of children with CF, these substances become thick, and cause ducts (passageways between organs) to become blocked, resulting in fewer enzymes.

    3. With fewer digestive enzymes, your child will have difficulty absorbing the nutrients, her body needs, especially:

    • fats
    • some proteins
    • fat-soluble vitamins such as A, D, E and K

    How can cystic fibrosis cause diabetes?

    In addition to affecting the respiratory and digestive systems, cystic fibrosis can also lead to diabetes. This is because problems with the pancreas may become so severe that some of its cells are destroyed, leading to glucose intolerance and insulin-dependent diabetes.

    About 35 percent of CF patients develop this type of diabetes in their 20s, and more than 40 percent develop the disease after age 30.

    What other risks are associated with CF?

    A small number of patients may also develop liver disease. Signs of liver disease include:

    • enlarged liver
    • swollen abdomen
    • yellowish skin
    • vomiting of blood

    Nutrition and cystic fibrosis

    How many calories does my child need?

    Your child will need to ingest more calories than someone without CF for two reasons:

    • Her body may have difficulty absorbing nutrients.
    • It takes a lot of energy to fight infections and compensate for breathing problems.

    The dietician on your child’s health care team will work with you to come up with a diet plan, but a good rule of thumb is to have her eat three meals and two to three snacks each day.

    Does my child need extra vitamins?

    Yes, your child may need to take extra vitamins. Vitamins A, D, E and K are known as fat-soluble vitamins, and since her body may have difficulty absorbing fats, it may be difficult for her to get enough of these vitamins from food.

    There are vitamins specifically made for children with CF, and we can recommend the type and amount that are appropriate for her.

    Does my child need extra salt?

    Yes, many children with CF need extra salt in their diets because they lose more salt in their sweat than other children. You can add extra salt simply by adding salt to her meals and serving salty foods and snacks (chips, pretzels, fast foods, french fries, pickles, nuts and luncheon meats).

    Remember that extra salt intake is especially important in the hot weather when your child is playing outside and sweating.

    What if my child isn’t gaining weight?

    Your child may not grow or gain weight despite having a high-calorie diet. If this happens, she may need supplemental feedings, as directed by her physician. This may involve her coming to the hospital.

    Sometimes, patients with CF require long-term nutritional support through a feeding tube (gastrostomy or "G-tube") through the stomach wall.

    Teens and CF

    It can be hard enough to be a teenager without having to deal with a chronic illness like CF. The adolescent years can be especially intense to a teen with CF, and may lead to some poor decisions about how he takes care of himself. Understanding what your child is going through can help you support him during this important time - and help you cope, too.

    Your child’s cognitive development

    Research suggests that the brain isn’t fully developed until a person’s mid-20s. Because your child’s brain is still developing, there’s lots of “in the moment” thinking: Your teen may have a hard time thinking about the consequences of his actions.

    This can lead to risk-taking behaviors, like substance abuse and sexual activity. And in the case of those with CF or other chronic illnesses, not taking medications and/or following through with chest therapy.

    Your child’s emotional development

    A big part of adolescence is navigating the territory between the security of childhood and the independence of adulthood. You may notice your child:

    • wanting more responsibility and to make his own decisions
       
    • testing boundaries and seeing how much he can get away with
       
    • exploring his own identity – figuring out who he is, what’s important to him and where he is headed in life

    As part of this process, he may choose not to follow through with this treatment plan (known as “non-adherence”). This could happen for several reasons:

    • If he’s been feeling good and not getting sick, he may feel that he doesn’t need it.
       
    • He may feel a strong desire to feel “normal” and not have the requirements and restrictions that make him feel different from his peers.
       
    • He may resent the need for close monitoring of his health.
       
    • He may find it difficult to incorporate his treatment regimen into his daily routine.

    Because of these things, he may feel angry and forget to do chest therapy and take medications.  

    How you can help

    Your support and understanding are more important than ever to your teen. Coping with a chronic illness is a stressful and emotional experience for teens and their families, and sometimes this can strain communication. Remember that good communication goes both ways:

    • Encourage your child to talk openly with you.
       
    • Keep your initial focus on listening to what your teen is saying, and making sure you understand what he means. Sometimes what a teen needs most is simply to feel understood. 

    Here are some other ways you can support your teen:

    • Include your teen in decision making about his health care as early as appropriate.
       

    • Talk with your child about his medication. Make sure he knows what he’s taking and why. Stress the importance of taking the medication as prescribed. Help him figure out ways to be reminded that it’s time to take the medicine (such as setting an alarm on his cell phone).

    • Encourage your child to find online peer support among other CF patients. This can decrease his sense of being “different,” and reassure him that what he’s going through is normal.

    • Help your teen to set long-term academic and vocational goals.

    • Teens like to feel like active contributors to the family. Encourage your child to do chores and care for younger siblings. Sibling support is also important.

    • If appropriate, help your teen identify a trusted adult he can talk with about issues that he may not be comfortable talking to his family about.

    • Support your teen’s efforts to develop and sustain friendships and other social relationships.

    Causes

    What causes cystic fibrosis?

    Cystic fibrosis is a genetic disease. Two things are true of all genetic diseases:

    • Their root cause is located on the cellular level.
    • They are inherited.

    Because of this, we can look at what causes cystic fibrosis in two different ways—how it occurs on the cellular level and how a child comes to inherit the disease.

    On the cellular level

    As the name implies, a “genetic disease” is caused by something in the body’s genes. Genes are found on chromosomes—structures in the cells of our bodies that usually come in pairs.

    One pair of chromosomes includes a gene called the CFTR (cystic fibrosis transmembrane conductance regulator) gene, and mutations or errors in this gene are what cause CF. This gene is large and complex, and more than 1000 different CF-related mutations have been identified.

    Inheriting CF

    If a baby is born with CF, it means she has inherited two CF genes: one from the mother and one from the father.

    A person with only one CF gene is healthy and said to be a "carrier" of the disease. If both parents are carriers of the CF gene (they each have one copy of the defective gene, but do not have the disease themselves), their child has:

    • a 25 percent chance of inheriting both defective copies and having CF
    • a 50 percent chance of inheriting one defective copy and being a carrier
    • a 25 percent chance of not having CF and not carrying the gene

    This type of inheritance is called "autosomal recessive."

    What does autosomal recessive mean?

    Autosomal means that the gene is on one of the pairs of chromosomes that do not determine gender, so that the disease equally affects males and females.

    Recessive means that two copies of the gene, one inherited from each parent, are necessary to have the condition.

    Symptoms

    The symptoms of CF differ for each child, and some children may not show signs of CF until later in life. Symptoms related to the respiratory system include:

    • chronic cough
    • coughing up blood
    • collapsed lung
    • clubbing (rounding and enlargement of the fingers and toes)
    • heart enlargement
    • nasal polyps (fleshy growths in the nose)
    • sinusitis (inflamed nasal sinuses)

    Symptoms related to the digestive system include:

    • frequent, bulky, greasy stools
    • rectal prolapse (a condition in which part of the lower intestinal tract comes out of the anus)
    • fat in the stools
    • stomach pain
    • bloody diarrhea
    • poor growth
    • gallstones

    Infants born with CF usually show symptoms within the first year. Your infant may be tested for CF if he has the following symptoms:

    • diarrhea that does not go away
    • foul-smelling stools
    • greasy stools
    • frequent episodes of wheezing
    • frequent episodes of pneumonia
    • persistent cough
    • skin tastes salty
    • poor growth
    • chronic sinus infection

    FAQ

    Q: What is cystic fibrosis?

    A: Cystic fibrosis (CF) is a common hereditary (inherited) chronic disease that affects two parts of your child’s body - her lungs and digestive system.

    Q: What is the life expectancy for a child with CF?

    A: The current life expectancy for someone with CF is about 37 years old—but those patients haven’t had lifelong treatment based on the most recent scientific advances. Today, a baby with CF is more than likely to live into her 40s and beyond.

    Q: If my child has CF, what are the chances that I could have another child with CF?

    A: Once parents have had a child with CF, there is a one in four, or 25 percent, chance with each subsequent pregnancy for another child to be born with CF. This means that there is a three out of four, or 75 percent chance, that another child will not have CF.

    Q: If CF is genetic, how can my baby have it when my partner and I don’t?

    A: Even though it’s an inherited disorder, finding out that your child has CF might be a surprise, since most of the time (in eight out of 10 families) there is no previous family history of CF. But many autosomal recessive conditions (which require that each parent contribute a gene with a mutation, even if neither actually has the condition) occur this way; since both parents are healthy, they may not known that they carry the gene.

    Q: Can you be tested for mutations in the gene that causes CF?

    A: Yes, testing for the CF gene can be done from a small blood sample. Laboratories generally test for the most common mutations, and most labs test for anywhere from 30 to 100 total mutations.

    Unfortunately, not all of the genetic errors that cause the disease have been discovered. Because not all mutations are detectable, a person may still be a CF carrier even if testing shows no mutations.

    Q: Can genetic testing prevent or stop my child’s CF?

    A: Unfortunately, knowing the specific genetic mutation doesn’t tell us when your child will become sick, nor how sick he may get. Two children with the same genetic mutation may show different symptoms at different times.

    That said, genetic testing is useful in that some therapies are effective for certain mutations and not others. This means that knowing the precise mutation can help us better target your child’s treatment.

    Q: Should I undergo genetic testing for CF?

    A: We recommend that you test for the CF gene if you have a family member with the disease, or if your partner is a known carrier of CF or affected with CF.

    Q: How sick will my child get if he has CF?

    A: Unfortunately, there’s no way of knowing how any individual case of CF will progress, but many CF patients lead full and happy lives. Following the treatment plan, performing therapies and taking medicines will help to ensure your child’s best possible outcome.

    Q: Is there a cure?

    A: At the present time, there is no cure for CF, but with medical and psychosocial support, many children and adolescents with CF can cope well and lead a productive life. The goals of treatment are to ease severity of your child’s symptoms and slow the progress of the disease.

    Q: What are the treatment options?

    There are a variety of treatments and therapies available for CF, and your child’s doctor will recommend the most appropriate ones for your child.

  • The first step in treating your child is forming an accurate and complete diagnosis. All newborns in Massachusetts — and most other states — are screened for cystic fibrosis. If doctors suspect that your child has CF, they will want to perform a sweat test.

    This is to make an area of your child’s skin sweat enough so that doctors can collect some sweat and determine how much salt (sodium and chloride) is in it. A high level indicates CF. The test takes about 40-45 minutes from start to finish. We perform about 1,250 of these tests each year.

    What happens during the test?

    1. Preparation

    We start by putting two gauze pads on each if your child’s forearm (or thigh, if your child is very young). The pad closest to the wrist has a mild chemical in it and is used to stimulate or activate the sweat glands. It feels like water.

    2. Stimulation

    We then attach electrodes to the pads and run a small current through them. This part of the test lasts 5 to 10 minutes and may not cause any sensation, or your child may sense a mild tingling. The test doesn’t hurt.

    3. Collection

    After 5 to 10 minutes, we wipe the sites with water, dry your child’s arms and put pre-weighed gauze on the sites that were stimulated. The gauze is then covered with plastic wrap, secured with tape, and left in place for 25 minutes. During this time, your child can sit in the hallway or go for a walk and is allowed to eat.

    4. Analysis

    After the waiting period, the gauze pads are removed and analyzed for salt content. Although the results are not ready immediately, we call them into your primary care physician's office on the day of the test.

    Your child’s doctor may also order one or more of the following:

    • blood tests - we can test your child’s blood cells for mutations in the CFTR gene. Other blood tests can assess infection and tell us whether other organs may be involved.
       
    • chest x-rays
       
    • pulmonary function tests to measure the lungs' performance. In these tests, your child will simply breathe into one or more special machines.
       
    • sputum cultures - a sputum culture (performed on the material that is coughed up from the lungs and into the mouth) is often done to test for infection.
       
    • stool evaluations to measure stool fat absorption
       
    • pancreatic function tests to assess the pancreas

    After we complete all necessary tests, our experts meet to review and discuss what they have learned about your child's condition. Then we’ll meet with you and your family to discuss the results and outline the best treatment options.

  • At the present time, there is no cure for CF, but with medical and psychosocial support, many children and adolescents with CF can cope well and lead a productive life. The goals of treatment are to ease severity of your child's symptoms and slow the progress of the disease.

    Your child's treatment is likely to include:

    • chest physical therapy to help loosen and clear lung secretions. This may include postural drainage and devices such as a percussor or flutter, which vibrate the chest wall and loosen secretions
       
    • exercise to loosen mucus, stimulate coughing and improve overall physical condition
       
    • medications to reduce mucus and help breathing, such as bronchodilators and anti-inflammatory medications
       
    • antibiotics to treat infections
       
    • management of digestive problems, which may involve:
      • appropriate diet
      • pancreatic enzymes to aid digestion
      • vitamin supplements
      • treatments for intestinal obstructions
      • dietary supplements
         
    • psychosocial support to help deal with issues relating to independence, sterility, sexuality, financial issues and relationships

    Lung transplant

    A lung transplantation – usually a double-lung transplant – may be an option if your child has end-stage lung disease. A lung transplant replaces the diseased lungs with a healthy pair of lungs. But this won't “cure” CF because the CF gene is in all of the cells in your child's body, and not just in her lungs.

    Is gene therapy a treatment option?

    Not at this time, although there are studies looking into it. The challenge is that the genes need to be targeted at the linings of the lungs and the airways, but those linings are being continually shed. Researchers are looking for a way to get the cells to stay and work as lifelong therapy.

  • The Cystic Fibrosis Center at Children’s Hospital Boston is part of the most extensive research enterprise in the world located at a pediatric hospital. We also have the greatest level of partnerships with the top research, biotech and health care organizations in Boston, working together to improve kids’ health.

    Our research has three goals:

    1. Develop new therapies

    We help determine the effectiveness of new drugs including inhaled antibiotics through participation in large studies conducted through the Cystic Fibrosis Foundation’s Therapeutic Development Network.

    2. Contribute to a greater understanding of CF

    Our investigators are looking for ways to stop CF complications before they begin, including being able to determine early signs of kidney injury.

    3. Improve your child’s quality of life

    At our Cystic Fibrosis Center, we’re examining the psycho-social aspects of living with CF, including learning what might make patients less inclined to follow through with their treatment, and how we can help them overcome their reluctance to do so.

    Read more about our research.



    Cystic fibrosis: Reviewed by Debra Boyer, MD
    © Children’s Hospital Boston, 2010

  • Michelle's story

    Man, oh man, oh man, where to begin?

    Isn’t that what some of you reading this would ask yourself if invited by Children’s Hospital to “share your story,” the story of being a parent to your amazing child?  Your amazing child because he or she is yours and had to be hurting at some level to even be in a hospital in the first place, right? 

    That’s what I asked myself when I first visited with the folks here about my Michelle and our experiences together as we’ve charted the waters of her myriad medical complications. 

    Michelle is 12 years old and beautiful.  Sweet as can be.  Not a mean bone in her body. 

    Though unable to speak, her eyes dance and her face lights up a room.  Occasionally she grimaces or whimpers, but oh-so-rarely, and only for very good cause. After all this time, I can figure out just about everything she “says.”  She is also unable to walk, her delays—and the mild seizures she suffers nearly every day—were caused by a rare, genetic form of intellectual disability known as Lissencephaly, diagnosed just after she turned one.

    But it was the very day after Michelle was born that life as I knew it changed forever (which happens after giving birth to even a healthy child, no?).  With a distended abdomen and an unwillingness to eat, she was flown from our small rural town to Children’s.  I’d had a C-section, so she had to go alone.  Torture.

    Three days later, still apart from my teeny precious love, I learned of her diagnosis of cystic fibrosis, according to the Web, “A life-threatening disease…” Life-threatening.  Stop right there.  That thought was paramount for days.  Days?  Try months.  Life-threatening.

    Other diagnoses were to follow.  One of them:  hip dysplasia.  Surgery scheduled in 2006 to correct it was overruled when uncontrolled seizures took precedence and the risks of so difficult an operation outweighed its benefits.

    But the brilliant Dr. Brian Snyder, who has followed Michelle for many years, predicted—astutely—that eventually he’d have to go in and fix what was amiss.  When Michelle’s left hip became dislocated last December, that time had come.

    In the intervening years, Michelle was diagnosed with CF-related diabetes.  At the time, I thought, “Oh, God, please, not something else.  I just won’t be able to handle it.”  But when I reflect on that time, I recall the wise words of my faith-filled mom:  “The human mind can get used to just about anything in 10 minutes.”  My initial reaction to her CF diagnosis notwithstanding, blood sugar checks and insulin shots simply became just another part of the very-busy-but-really-not-that-complicated routine.

    And once you overcome that hurdle of learning a new medical regimen (and, of course, the gut-wrenching feeling of what does this mean for my child now?), what’s left is the adoration and purity of a living, breathing angel who is your very own daughter.  Unbelievable.

    Anyway, I didn’t know but should have known—the most significant dilemma of the “hospital” parent—that this latest CFRD diagnosis would impact Michelle’s recovery of the surgery that was to come.

    As I sat in the comfortable suite of OR waiting rooms that March afternoon, I never dreamed it would be 1 a.m. before I would finally see Michelle again, in the Intensive Care Unit (ICU).  Had she not been a patient there before, I honestly believe that at the sight of her I would have crumbled to the floor with that mix of despair and exhaustion many parents know all too well.  (But, somehow, we remain standing.)  There she was, breathing tube down her throat, puffed up from excessive fluid retention, both legs in a giant double cast, and completely and totally in another world.  Though her nurse looked all of 19, it was clear within minutes she knew her stuff.  She administered meds, checked “PICC” lines, monitored monitors, consulted pain management specialists, doctors, and fellow nurses, chatted comfortably and reassuringly with me, and simply “did her job” (oh, what a job) with an efficiency and alacrity that would astound Donald Trump. 

    I crashed.  In clean sheets on the bed for me in Michelle’s room. 

    Later that morning, my number one priority was coffee.  Well, that’s the case on the best of days, so you can only imagine.

    I returned to the ICU to doctors of all stripes (students, residents, fellows, attendings—you get the hierarchy down after awhile), pow-wowing outside Michelle’s door. 

    Anesthesiology.  A tricky practice indeed.  The physician conducting this particular train (yet another OK-you-are-so-astonishingly-brilliant-but-very-kind human being typical of Children’s Hospital) had run into trouble with this critical component of Michelle’s procedure:  the epidural intended to manage Michelle’s pain locally didn’t work.  After three attempts.  So that meant heavy-duty narcotics and continued intubation. 

    The huddled doctors called me over to inform me that when drawing from the failed epidural, the nurse discovered spinal fluid, meaning a 2-3% chance of spinal chord damage.  A small percentage, yes, but not to me.  Could my love have had double hip surgery only to end up paralyzed from the waist down??

    Knowing it would be weeks before a neurological exam could reveal any response to touch, Dr. Snyder ordered an MRI for that day (thank you, God).  It took a full hour and a half to ready Michelle to simply leave her room, so connected was she to a vast array of monitors, IVs, and oxygen, all of which had to STAY connected while she underwent the procedure in the narrow MRI chamber.  Hours later, great news:  no compression of the spinal chord.  No leaked blood or other fluids. 

    The next day I had to go home, to return to work and Michelle’s eight-year-old sister, Simone.  Now, nothing is more important for a parent than helping “quarterback” the flow of communication among multiple medical professionals, let alone after a complicated procedure with so many different services at play (ortho, pulmonary, endocrine, neuro) working toward a difficult recovery.  But I knew that in the ICU, Michelle was too sedated to have any awareness of my absence and that she was in the best of hands; after a certain point, I was a bit in the way. 

    So home I went. 

    Then back again.  Back and forth.  A lot.  With frequent calls to Michelle’s nurses in between. 

    After nine days, she’d finally been “extubated” and soon thereafter transferred to 9 South, where she’s been for most of her stays at Children’s. How shall I describe the environment there?  Let’s just say that once, when telling my sister about it, she said, “Boy, I bet you’re hoping Michelle ends up in the hospital again soon.”  Well, not quite.  But when you can count among the nurses, CAs, receptionists, and custodians a multitude of lifelong friends, you know it’s pretty special indeed.

    And the extra comfort it gave me to have Michelle in the care of 9 South’s extraordinarily skilled and unbelievably kind nurses made all those trips back home a little more bearable.

    As Michelle’s parent, I’ve frequently found myself torn between letting the experts do their thing and being, frankly, a pain in the ass.  The trick is to do the latter while maintaining mutually respectful relationships.  I’ve learned that at the risk of losing it a bit from time to time, I am Michelle’s foremost advocate, her mother lion, and if noses get bent out of joint in the process of assuring her maximum well-being and comfort, I nonetheless do what I must do. 

    Fortunately the people who know me best understand that Michelle is my primary focus, and that if it means letting off a bit of steam, insisting on swift, clear answers to countless questions, or answers to questions I’ve not yet even formulated, well, that’s cool with them.  (It’s even okay to cry; there is always a shoulder available if I need it.)  I think the nurses especially would far prefer to see a parent passionately engaged than dutifully polite, too intimidated to challenge, or (the saddest of all), remote and uninvolved. 

    It’s been a long road, and she’s a ways to go with the healing of that nasty wound.  I could question endlessly:  How could this happen?  Should the cast have been removed sooner?  Could I have more aggressively intervened?  But everyone did more than their best, and my little girl and I shall soldier on. 

    It was Michelle’s most recent admission, but it won’t be her last.  It’s been another learning experience for Mom, and a further strengthening of the respect, gratitude, and sincere fondness I feel toward the people that make up the best pediatric hospital in the country – the best, to me, in the whole wide world.

    How immeasurably blessed we are, despite the challenges we face, that these amazing, gifted, dedicated men and women play such an important role in our lives.

    Who would ever have known?  Who would have known that this story would be . . . our story.

    - Ann Davis

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