Kapi`olani Kids | Spring 2006

kids

Kapi`olani VOLUME VOL 1. ISSUE 4. ISSUE 1 1. MAY 2006

T H E L AT E S T I N C H I L D R E N ’ S H E A LT H F R O M K A P I ` O L A N I C H I L D R E N ’ S H O S P I TA L

Get Into The Swim of Things — Safely Keep a constant watch on children to prevent drowning

BABY TALK Kapi`olani Uses New Screening Test to Prevent Newborn Brain Damage The latest addition to Kapi`olani’s regimen of newborn screening tests helps pediatricians prevent irreparable brain damage.

Following the recommendations of the American Academy of Pediatrics, Kapi`olani implemented this screening test last year. It detects severe jaundice that can lead to kernicterus, a condition that can cause lifelong brain and physical impairment.

“Jaundice is caused by a buildup of a pigment called bilirubin,” says Stephen Yano, M.D., pediatrician at Kapi`olani.

Stephen Yano, M.D. During pregnancy, bilirubin is processed by the mother’s liver and is flushed out of the body. Following delivery, the infant’s liver needs to “wake up” or begin continued on page 6

Quickly and quietly, hundreds of children in the United States will drown this year — often with adults just yards away.

Drowning is one of the leading causes of fatal injury among children up to age 14, accounting for about 17 percent of all such deaths. (Motor vehicle accidents are the most common cause of death in this age group.)

As Hawaii’s children’s hospital, Kapi`olani’s physicians are all too familiar with these statistics. “We see more than 20 neardrowning cases each year in the pediatric intensive care unit, and many more children are treated in our emergency room,” says Rupert Chang, M.D., pediatric intensivist physician at Kapi`olani. “A number of the children requiring intensive care will suffer significant Rupert Chang, M.D. brain injury resulting in lifelong disabilities.

These children will usually require extensive assistance and support services at home.”

Because not much can be done to reverse brain damage once it

occurs, says Dr. Chang, Kapi`olani emphasizes injury prevention and rapid initiation of CPR when accidents do occur.

“Many of these tragedies are preventable with proper precautions,” he says.

Keeping children away from bodies of water through the use of barriers is an important method of accident prevention. However, enclosing pools with fences and self-closing gates cannot replace close adult supervision.

Many parents think a child is safe in the water when an adult is nearby. But consider this: 88 percent of children who drowned in 2000 and 2001 were continued on page 6

Kapi‘olani Children’s Miracle Network Telecast

“Medicine, Miracles and Aloha” KITV–Channel 4 (ABC), Thursday, June 8, 2006, 8–9 p.m.

An exciting look at the miracles of Hawaii's only children's hospital. Learn about the latest treatments for prematurity, genetic abnormalities and life-threatening illnesses such as cancer. Find out how Kapi‘olani benefits our island keiki.

808-535-7100

www.kapiolani.org

[ health bits ] New Steps May Help Block SIDS Putting babies to sleep on their backs has caused a sharp drop in sudden infant death syndrome (SIDS). Yet doctors still blame SIDS for more U.S. infant deaths than any other cause. The American Academy of Pediatrics (AAP) has revised its SIDS advice to deal with some new issues. The AAP: ■ No longer thinks it’s OK to put babies to sleep on their sides. Every caregiver

should put a baby to sleep face up for each sleep period.

■ Doesn’t recommend bed sharing during sleep. You can bring infants into your bed to nurse or comfort them, but put them back in their cribs or bassinets (perhaps in your bedroom) when you want to go back to sleep.

■ Suggests you use pacifiers, after breastfeeding is well-established, at nap time

and bedtime through the first year of life. Research shows a link between pacifier use and reduced SIDS risk.

The AAP also urges parents to use a firm sleep surface, keep soft objects and loose bedding out of cribs, and not smoke during pregnancy or around the baby.

The ABCs of Enough ZZZs Wake up to the need to help your child get adequate sleep A good night’s sleep is as important to your child as a hearty breakfast. Without enough sleep, studies show that children are more prone to struggle while playing sports or studying in school, have more emotional breakdowns and suffer depression.

Yet 69 percent of children in the U.S. have one or more sleep problems a week, according to the National Sleep Foundation (NSF). That includes trouble getting to sleep or staying asleep. Children are sleeping less today — about four hours less a week — than they did a decade ago.

“Lack of sleep results in poor school performance because these children are sleepy, more irritable and moody during the day,” explains Vince Yamashiroya, M.D., a pediatrician in Honolulu. “Studies have shown that sleep deprivation can affect higher-level mental tasks, such as those involving memory. It can affect the immune system, leading to an increased risk of infection. Also, long-term effects can include high blood pressure, diabetes and heart problems.”

Vince Yamashiroya, M.D.

2 Kapi`olani Children’s Hospital 808-983-6000

In younger children, lack of sleep is often a control issue, such as resisting bedtime.

“They are at that age when they are stubborn, and don’t want to do things they are supposed to. It’s the ‘no’ years,” says Dr. Yamashiroya. In older children, the causes are varied, he says. Some children, labeled as “high achievers,” may lack sleep due to homework and the many activities they are involved with. Other children may just lack sleep due to poor habits, such as watching TV or playing video games at night.

The best cure, he says, is a consistent bedtime schedule. Stick to a bedtime that permits your 3- to 5-year-old child to get 11 to 13 hours sleep. A school-age child needs 10 to 11 hours. If the current bedtime is too late, move it 15 minutes earlier each night. Also, parents should tuck resisters back into their own beds, promptly and repeatedly, until they get the message that you expect them to get to sleep on their own.

In addition, the following are some tips that can help your child improve his or her sleep: ■ Unplug the bedroom. Turn off TVs, computers and cell phones. However, it would be much better if these things were kept out of the bedroom, which should be a stimulation-free zone.

■

Set a wind-down routine. A good example would be to have a warm bath, brush and floss teeth, and end with reading a book. Avoid watching TV just before bedtime.

■ Go decaf. Drinking any caffeine during the day affects sound sleep. Caffeine is present not only in coffee and cola, but also in tea and chocolate.

■ Reduce daytime stimulation.

Overworked children who rush from band practice to dance class to dinner to homework may be too keyed up at bedtime to unwind. It is better to do one activity per season.

■ Get help. If, despite these measures, your child still resists bedtime, has nighttime awakenings, or snores loudly and has difficulty breathing during his or her sleep (a sign of sleep apnea) talk to your doctor. Check out the NSF’s Web site at www.sleepfoundation.org.

TEEN CORNER

Signals Teens Send That Mean They Want Help: A sudden, dramatic drop in academic performance ■ A change in friends, eating, sleeping, dress or favorite activities ■ Fighting or getting arrested ■ Substance abuse ■ Sexual promiscuity ■ Making comments about wanting to hurt themselves or others When your teen is sending these SOS signals, it may be time to get help. But remember, that doesn’t mean you must seek out a licensed therapist.

Your minister, aunt, or anyone else your child identifies with and you trust may be able to help. “Adolescence is a time when teens are reaching for independence. This normal, appropriate part of growing up can be scary for teens and parents alike. It’s the next step in growing up. The goal is to keep family relationships in place,” says Hirsch.

■

Teen Talk: Recognizing Your Youngster’s SOS Signals If your child’s adolescence is proving tough for both of you, good communication may help improve your relationship and your child’s behavior It’s past midnight, and once again your unruly adolescent has broken curfew.

Finally, she arrives home. When you ask for an explanation, she races past you without a word, runs to her bedroom and slams the door shut.

Infuriating? You bet. But whatever you do, don’t react on your emotions. “Instead, stay calm. Get the facts, and after everyone’s had a chance to cool down, talk things out,” says Wendi Hirsch, Ph.D., child psychologist at Kapi`olani who specializes in adolescents.

Hirsch offers several tips on how to communicate effectively with your teen when there is a problem: ■ Go to a neutral setWendi Hirsch, ting. If possible, have Ph.D. both parents present.

■ Make sure other siblings or people are not there.

■ Start out by saying, “I am concerned about ...”

■ Don’t pass judgment or be defensive.

■

Take a few moments to consider a logical, natural consequence.

■ Do not use physical punishment. This will not work and will likely worsen the problem.

■ Some teens communicate better in writing. Encourage your teen to write down her feelings.

■ Start with common areas that you agree on and establish some rules for the future.

When things settle down and times are good, review the boundaries you set. For example: “You know your curfew. If you break it, you have crossed the line and the consequence will be ...” Remind your teen of all the good times you have had together and that you always have and always will be there for her.

But, sometimes no matter how hard you try, things still don’t come out right. “And the scary thing for parents is that sometimes there is no clear signal,” Hirsch says.

Still, there are ways to tell if your child is having significant problems. See “Signals Teens Send That Mean They Want Help” at right.

www.kapiolani.org 3

Very Special Team Assembles For a Very Uncommon Birth JAIMIE KUWAHARA WAS IN HER 14th week of pregnancy when the results of a routine blood test showed elevated levels of maternal alpha-fetoproteins. Her obstetrician called her in for a detailed prenatal ultrasound. “They saw that the baby had some kind of mass by her stomach,” the first-time mom from Hilo recalls.

“Along the way, all of my doctors were really great in explaining to me how things would go. They were very comforting.”

—Jaimie Kuwahara

A team effort The discovery set in motion a sequence of events leading to the assembly of a highly specialized team of doctors and nurses who were on hand for the birth of little Mya Lisa. She was born in Honolulu at Kapi`olani Medical Center for Women & Children earlier this year with gastroschisis, an uncommon birth defect that produces an opening in the abdominal wall. As a result, the baby’s intestines were on the outside of her body.

Mya Lisa was born with her intestines outside of her abdomen.

Dr. Johnson performed the surgery right in the delivery room, carefully placing the infant’s intestines back inside.

4 Kapi`olani Kapi`olani Children’s Children’s Hospital Hospital 808-983-6000 808-983-6000

The cause for gasSid Johnson, M.D. troschisis is unknown, but its treatment is immediate. In this case, Pediatric Surgeon Sid Johnson, M.D., a neonatologist, a pediatric anesthesiologist and many others with special training, equipment and instruments were ready and waiting in Kapi`olani’s Labor, Delivery and Recovery suite. Dr. Johnson performed the surgery right in the delivery room, carefully placing the infant’s intestines back inside.

“I like to be there when the baby is born,” he says. “With Mya Lisa, I placed the intestines in a special bag on the abdomen to keep them sterile and connected to her body. The bag allows me to slowly place the intestines back into the abdominal cavity. I did the final reconstruction of her abdominal wall the following day,” says Dr. Johnson.

at the Harvard School of Medicine, which required three years. He spent another year there to complete a fellowship in clinical bioethics. Prior to Harvard, Dr. Johnson had spent five years to complete a general surgery residency at the University of Utah, after four years of study to receive his medical degree at Utah. In all, Dr. Johnson prepared with 13 years of post-graduate study in order to be in the delivery room on the early evening of Jan. 31 when Mya Lisa arrived in need of his care.

“A pediatric surgeon is essentially a general surgeon who has done specialty training to devote his practice to surgical problems of babies and children,” he explains. “A neonatologist is essentially a pediatrician or medical doctor with training devoted to high-risk neonates, or very small babies. I focus on the babies with problems I can fix surgically. There are maybe 12,000 or so births every year in Hawaii. As such, there are frequently babies with some congenital problem who need an operation.”

Education leads to understanding Although it was an eye-popping diagnosis, Kuwahara became well-informed about the defect and what was ahead. “I went on the Internet and looked it up like any parent would do, just to educate myself.”

Several weeks before her due date, Kuwahara came to Oahu, where she stayed with her grandparents. She was referred to Dr. Johnson, who talked to her about the pediatric surgical procedures to come. “Along the way, all of my doctors were really great in explaining to me how things would go,” recalls Kuwahara.

“They were very comforting. They helped me to understand that gastroschisis is just a birth defect that happens and they don’t know why.”

Experience makes a difference While Kuwahara had several months to learn about her baby’s special condition, Dr. Johnson has spent more than a decade preparing to help infants with all kinds of conditions. He joined Kapi`olani in 2005 after completing a pediatric surgery fellowship and critical care fellowship

“Kapi`olani is the largest facility dedicated to the care of infants in Hawaii. It’s designated as a Level III hospital — one of the most sophisticated you can get.”

—Sid Johnson, M.D., pediatric surgeon

Dr. Johnson says that physicians like him “need to be at places where we have people with special training in pediatric care. They also need instruments and tools that are small. An instrument you might use for a gallbladder with an adult might be four or five times smaller for an infant.

Kapi`olani is the largest facility dedicated to the care of infants in Hawaii. It’s designated as a Level III hospital — one of the most sophisticated you can get.”

The critical moment Kuwahara’s water broke at about 11 p.m. Jan. 30, and she was checked into Kapi`olani by midnight. When Mya Lisa was born at 5:37 p.m, “everyone was crowded

Surgery for Kids Requires Very Special People and Equipment

Jaimie Kuwahara holds her daughter, Mya Lisa. Mya was born at Kapi`olani Medical Center for Women & Children, where she received lifesaving surgery and specialized neonatal intensive care.

around her and everything happened so fast,” Kuwahara recounts. “There was a whole bunch of staff there — neonatology staff, lots of nurses. I couldn’t really see what was going on, but as soon as she came out they took her to a table. The neonatologist assessed her, and then Dr. Johnson did his part. My mom, dad, husband, grandma — everybody was there.”

A happy ending Soon after the surgery, Mya Lisa was able to leave the neonatal intensive care unit and move to Kapi`olani’s Intermediate Nursery, where she made a full recovery.

Kuwahara was thrilled to take her baby home, and was grateful for all the care provided during Mya’s first weeks of life.

“They can care for her a hundred times better than I could have at home. I thought I would be an emotional wreck, but I

wasn’t. Being prepared was one of the best things. The doctors and nursing staff are great. I don’t think I would have taken all this as well if it weren’t for them. It’s been a crazy couple of months, but it’s really important they educated me. Being prepared made all the difference,” says Kuwahara.

For more information on having a baby and the specialized care for newborns and children only available at Kapi`olani, call 808-535-7000.

Kapi`olani Kids is printed by Kapi`olani Medical Center for Women & Children. This is the May 2006 issue.

Kapi`olani Kids is published twice a year as a service to parents in the community served by Kapi`olani Medical Center for Women & Children, 1319 Punahou Street, Honolulu, HI 96826.

The information is provided as education about physical, mental and psychosocial health. It is not intended as a substitute for consultation with a physician. If you have questions or concerns about specific items that appear in Kapi`olani Kids, please contact your child’s doctor. To advise us of changes to your mailing address, please contact us at 808-535-7554.

Any medical operation requires special training. But there is a world of difference — some of it not readily apparent — when the surgical patient is a child.

Kids are not simply “miniature adults” when it comes to the most appropriate surgical care.

The proportions of their bodies are distinctive, as are the ways their cardiac, respiratory and other systems function.

Children also suffer from diseases and problems that are not seen in adults.

They are still growing and changing in ways that adults do not, and their social and psychological needs are different.

Children often require special understanding because they can’t say what’s bothering them or answer medical questions.

Pediatric specialists train for years to address the needs of children — from newborns to teens — and their families.

The pediatric anesthesiologist is a physician who spends a year of fellowship working with newborns, premature infants and children, and is adept at administering medication safely. These specialists are skilled at minimizing pain and trauma for children who are undergoing procedures or surgery, or are experiencing pain due to a medical condition or injury.

When a pediatric condition is rare, as in the case of Mya Lisa Kuwahara (see story at left), the best possible outcome is most likely with the participation of a pediatric surgeon who spends two years or more in a pediatric surgical fellowship.

These highly skilled specialists are trained to treat unique childhood conditions.

Kapi`olani operates the only Level III neonatal intensive care unit in Hawaii, with neonatologists on site around the clock. Also available for emergency cases at all times are pediatric anesthesiologists, pediatric surgeons, pediatric staff and the specialized equipment needed for infants and children.

www.kapiolani.org 5

Water Safety continued from page 1

supervised by a parent, grandparent or baby-sitter, according to Safe Kids Worldwide.

“Parents think just being nearby is sufficient to save their child,” says Safe Kids Worldwide Program Director Angela Mickalide, Ph.D. “Generally, parents misperceive drowning as a noisy event that takes a while. Actually, it happens suddenly and silently,” she cautions. “When children are trying to gasp for air, they can’t scream because they don’t have enough air in their lungs.” Dr. Mickalide says that very young children are at greatest risk of drowning in pools and bathtubs, while older children’s greatest risks are in open bodies of water, such as the ocean or rivers.

Kapi`olani Gets Babies Off to a Healthy Start All newborns receive hepatitis B vaccine before going home Following the recommendations of the American Academy of Pediatrics, Kapi`olani Medical Center for Women & Children now vaccinates all newborns for hepatits B before they go home, with their parents’ permission.

Hepatitis B is a serious infection.

Long-term illness can lead to liver damage, liver cancer and even death.

The hepatitis B vaccine, administered in three separate doses, can protect against this infection.

The Kapi`olani vaccination program, which began last fall, administers the first of three doses of the vaccine prior to baby’s discharge from the hospital. Infants Douglas Kwock, receive the next two M.D. shots in their doctor’s offices. Kapi`olani is leading the way in the state to offer universal vaccination for newborns.

“Due to discussion in the media and various Internet sites,

6 Kapi`olani Children’s Hospital 808-983-6000

some parents have been led to believe that vaccines are harmful,” says Douglas Kwock, M.D., pediatric infectious disease specialist. “Parents need to know that the benefits of vaccination far outweigh the risks. Getting the hepatitis B vaccine is much safer than getting the hepatitis B infection.”

He adds that Kapi`olani has implemented special screening procedures to ensure that newborns with mothers who test positive for hepatitis B follow the recommended protocols that protect infants from acquiring the infection from their mothers. These expectant moms are identified prior to delivery, so newborns can receive the vaccine within the 12-hour window after birth.

“As with any medication, there are always potential side effects,” says Dr. Kwock. “Minor reactions include soreness at the site of injection and mild to moderate fever. Serious allergic reactions are very rare.”

If you have questions, please talk with your obstetrician or pediatrician during your pregnancy.

Preventing Brain Damage continued from page 1

functioning. The buildup of bilirubin turns the baby’s skin and the whites of the eyes yellow.

“Kernicterus results from staining of parts of the newborn brain and, if it occurs, can result in a 10 percent fatality rate and a 70 percent chance of poor brain development or seizures in those who survive,” says Dr. Yano.

Kapi`olani Medical Center for Women & Children is the first in the state to offer the screening for all newborns. The simple test uses a meter on the baby’s skin to measure levels of jaundice.

“The presence of mild jaundice is ‘normal’, however, severe jaundice can be life threatening or can cause brain damage,” Dr. Yano explains. Signs of severe jaundice may include a deep yellow color to the skin, poor feeding, lethargy, a high-pitched cry, increased stiffening and at the worst, seizures.

“We promote active supervision,” says Dr. Mickalide. “Designate someone as a ‘water-watcher,’ whose sole responsibility is to watch the children in the water for a distinct period of time, not talk to friends or supervise other kids,” she says.

Don’t be lulled into a sense of false security because your children can swim,

Dr. Mickalide adds. “Your eyes should be constantly focused on your kids in the water.”

“Ideally, the people supervising the children should be certified in CPR,” adds Dr. Chang. “Victims who receive effective CPR immediately after a near-drowning accident will have a better outcome than those with whom CPR was delayed.”

Lessons to Keep Your Kids Safe Oahu Swim Class Directory All Aquatics www.allaquatics.org 808-754-0268 Honolulu Leahi Swim School www.leahiswimschool.com 808-735-1666 Honolulu Swim Hawai’i www.swimhawaii.com 808-922-4192 Honolulu YWCA of Oahu www.ywcaoahu.org 808-538-7061, ext. 201 Honolulu, Kaneohe

New technology helps detect jaundice The “BiliCheck” monitor is the newest device used to monitor jaundice. Daily measurements make the pediatrician aware of rapidly rising values. Blood tests confirm the condition so early treatment can be started to prevent the potential damaging effects of severe jaundice.

Early treatment can prevent the complications of jaundice. Light energy, in the form of phototherapy lights, helps control the rise of bilirubin and allows time for the infant’s liver to begin detoxifying the pigment (bilirubin).

“The most important thing for the safety of your newborn is that you recognize the warning signs of jaundice. Follow up with your physician two to three days after returning home from the hospital.

Call sooner if you see signs of severe jaundice developing in your infant,” says Dr. Yano.

“With this new screening test for severe jaundice, Kapi`olani’s nursery is a safer place for our young infants.”

YMCA of Honolulu www.ymcahonolulu.org ■ Central Branch (Atkinson Drive) 808-941-3344 ■ Kaimuki–Waialae Branch 808-737-5544 ■ Nuuanu Branch 808-536-3556 ■ Mililani 808-625-1040 ■ Kailua Branch 808-261-0808 Kapi`olani provides this list of community resources only as a convenience and service to parents. Kapi`olani neither endorses nor makes any representations regarding the service or quality of service offered by the listed entities.

More Water Safety Tips From Safe Kids Worldwide ■ Install

a four-sided fence around a pool. The gate should be self-closing and have a lock.

■ Keep a phone nearby.

■ Hold babies when they are in the water.

Inflatable armbands are swimming aids, not flotation devices. They cannot be depended upon to keep infants safe.

■ Clear the pool area of toys when you leave.

Many young children who drown fall into a pool while reaching for a toy or ball.

■ Enroll children between ages 4 and 8 in a swimming class with a certified instructor.

Safe Kids Worldwide says 74 percent of children who drown don’t know how to swim.

■ Never leave a child alone near water, even a bathtub. Children can drown in as little as 1 inch of water.

■ Post CPR instructions and emergency phone numbers near a pool. Any adult supervising children near or in water should know how to swim. Ideally, they would be certified in CPR. ■ Be within arm’s reach of toddlers and children who can’t swim so you can reach out and grab them if you need to.

Danger Signs in a Newborn ■

Yellow discoloration that usually starts in the face, then progresses to the chest.

Jaundice may then spread to the stomach and legs. Examine your baby carefully in natural daylight or in a room with florescent lights.

■ If your infant has already been diagnosed with jaundice, call the doctor immediately if the baby’s skin color becomes more yellow, if jaundice spreads to the abdomen, arms or legs, or if the whites of the baby’s eyes become yellow.

■ Most babies have no other symptoms.

However, parents should call the doctor immediately or seek emergency care if baby develops increased sleepiness or is hard to wake, sucks or nurses poorly, appears weak or floppy, arches the neck or back backward, or develops a highpitched cry or fever. These may be early warning signs of dangerously high levels of bilirubin. www.kapiolani.org 7

Children’s Hospitals Combat Abuse and Promote Prevention Most parents don’t intend to hurt their child. But the stress of an infant who won’t stop crying or the daily trials of caring for a child with special needs can overwhelm even the most loving mother or father.

Whether you’re struggling to build positive discipline skills or have seen another parent or caretaker abuse a child but don’t know what to do, your local children’s hospital can help.

Nearly 3 million cases of suspected abuse and neglect are reported in the U.S. annually. Children’s hospitals are the undisputed leaders in providing medical care to abused and neglected children.

They educate parents and caretakers about how to cope with the frustration and anger they sometimes feel. Children’s

NACHRI National Association of Children’s Hospitals and Related Institutions www.childrenshospitals.net

hospitals provide classes, fact sheets and more to guide parents and caretakers through child rearing. They also offer support groups where parents and caretakers can find assistance and meet others who are struggling with the same frustration.

Don’t be afraid to reach out Worried that a child you know or see in a public place is being maltreated?

Children’s hospitals can help connect you to a community resource where you can report your concerns.

Some parents worry that if their child is injured by accident, not through abuse, they will be suspected of abuse at a hospital. Children’s hospitals are working on a seamless, timely and effective system of abuse response that helps protect innocent parents and provides medical care and emotional healing to the most vulnerable children.

Working with children’s hospital leaders, pediatricians and allied groups, the National

Association of Children’s Hospitals and Related Institutions (NACHRI) developed Defining the Children’s Hospital Role in Child Maltreatment, a guide to establishing, developing and enhancing child abuse services in children’s hospitals. These guidelines help facilitate the highest level of quality care to abused and neglected children.

Learn How to Protect Children For more on children’s hospitals’ efforts to prevent and treat abuse and neglect, visit www.childrenshospitals.net and select “Child Advocacy.”

If you’re concerned about a potential case of abuse, contact the Child Protective Services Hotline at 808-832-5300, or toll-free from the neighbor islands at 800-494-3991.

For more on positive parenting, contact Kapi`olani Health Connection at 808-535-7000.

Articles in this newsletter are written by professional journalists or physicians who strive to present reliable, up-to-date information. But no publication can replace the care and advice of medical professionals, and readers are cautioned to seek such help for personal problems. ©2006 Staywell Custom Communications, 780 Township Line Road, Yardley, PA 19067, 267-685-2800. Some images in this publication may be provided by ©2006 PhotoDisc, Inc. All models used for illustrative purposes only. Some illustrations in this publication may be provided by ©2006 The StayWell Company; all rights reserved. (206)

Would you like to continue to receive this newsletter?

Please be sure that you’re on our subscriber mailing list. There’s no charge. Look at the mail panel to the right. If it says, “Call 808-5357000 to subscribe,” you are not on our permanent mailing list.

Please visit www.kapiolani.org or call 808-535-7000 to sign up.

1319 Punahou Street Honolulu, HI 96826

Non-Profit U.S. Postage PAID Permit No. 733 Effingham, IL