Pharmacist - Dr. Marry Vuong 

 

Tovah Feehan: [00:00:00] Oh, we're so excited that you're here Marry from Perfecting Peds. I feel like it's one of those things where I had a pharmacy question, and then it's like, when you learn a new word, and then all of a sudden, like, I kept having pharmacy questions and what you and Perfecting Peds are doing is so amazing. So we're really excited to learn from you today. I have a lot of questions. 

Dr. Marry Vuong: Thank you. I'm so happy to be here. And like, it's kind of crazy because like, Bri was on our podcast a few, like, a few months ago, and it was just like a weird, like, you know, you you reached out to me through Jena because you know, Jena, and then I found Bri because I worked on a paper with Brooke and then Brooke brought Bri on.

So it's just like the world is so small, but it's honestly so beautiful. Like, I love how like interconnected and intertwined we can be. And honestly, SLPs are my favorite. So I'm happy to be here. Thank you for having me. And I guess a little bit about myself. I was like, I forgot that part. So my name is Marry Vuong. I am a pediatric pharmacist by trade, but I'm currently chief of staff for Perfecting Peds. And I have a background in nutrition, so that's probably [00:01:00] how this all melts together really well. 

Tovah Feehan: And I think it's important because I know for me as an SLP, I don't collaborate with pharmacy very much. And the more that I've been collaborating with you guys, the more I'm like, oh my gosh, this is really, really, really important. Could you tell us a little bit about Perfecting Peds and how it's different? Because there really isn't- Jena, so can I give a little background about Jena? 

Brianna (Bri) Miluk: Of course. 

Tovah Feehan: Okay. So I met Jena a few years ago around the time that I was starting my private practice and a friend introduced us a mutual friend, and she was just like, one of those people who is ready to take over the world. And you could talk more about the Perfecting Peds journey, but the way that you just shared that all of us are so connected, it was just like today was meant to be. And I feel like we could help so many families today with the things that you're going to share because so many of the children that we see with chronic illness are our complex kiddos.

They're on so many medications. And there are so many ways that we could streamline their care and make it better. So could [00:02:00] you tell us like that outpatient space that Perfecting Peds is in and how it's different? 

Dr. Marry Vuong: So the outpatient space is really different. I spent six years of my life working in a hospital where we had complete access to SLPs all the time. And I think like feeding and swallowing was like, what top of our list usually before discharge especially for like little kids and new diagnoses so I was so used to having like an SLP at my fingertips and we would do like all kinds of different swallow studies we would ask about the different consistencies and most of these kids had g tubes and things now that we're in the outpatient space, it's it's quite different. So Perfecting Peds is the first company to bring the pediatric pharmacist outside of the hospital. There's about 1900 pediatric pharmacists in the United States which is kind of crazy to think of.

It's only about 0.5 percent of the whole population of pharmacists practice in peds. And if you think about how many children there are, it's a little scary to think that not many people are specialized in this. So Jena Quinn is our founder and she worked at a bunch of hospitals in Camden, New Jersey.

She worked at Cooper University, [00:03:00] CHOP, and she realized that there was something wrong because a lot of these kids that were like complex kept like being readmitted and there was a reason and one of the reasons she postulated was because they weren't being followed by pediatric pharmacists outpatient.

Inpatient if you've ever worked with a pediatric pharmacist, we're on the care teams, we're rounding with the teams, we're pretty much at the disposal of the care team all day for any sorts of questions. And we see a holistic view of the patient. So we're the person that sees all the medications and not just like the specialist sees this, the neurologist sees this, like the pediatrician will only touch this.

The pharmacist is the one that has to like see the whole picture. So what she postulated is if we brought this pediatric pharmacist to the outpatient space, we'd have better outcomes. So she started off first just in like the long term care facility space in New Jersey and she took care of patients in three facilities and she was like, yeah, I think we are making a big change.

So she put this to practice and actually did a research study, which was [00:04:00] published in the Journal of Pediatric Pharmacy and Therapeutics in April of 2024. And the study found that in 102 patients, by having like that one pediatric pharmacist take care of them outpatient, they were able to reduce medications by 15%, readmissions by 44%, and they were able to save the facility about like 1.2 million dollars for 102 patients, which is kind of wild. So then she brought this data to health plans, and the first health plan that we contracted with was Health Partners of Minnesota. We're also with Geisinger in Pennsylvania, we take care of a lot of Medicaid patients and we're kind of like working our way through the country.

So she contracted with these health plans and told them like, hey, if you give me your most high cost, high needs patients, I'll be able to save you a bunch of money and also create better outcomes. So just by like having that specialist take care of a patient and see them as a whole patient instead of just like a silo of this is your brain, this is your stomach, these are your lungs.

It'll definitely help the like standard of care in the country so how I got involved with Perfecting Peds is my mentor Gabby [00:05:00] reach out to me and was like hey you'd, be perfect for this. Like maybe you should like you should look into this so I reached out to Jena on LinkedIn as ballsy as I've ever been in my life and I said, hey, you should hire me and she was just like, oh, you know, normally I don't respond to these messages because now that I like I see her LinkedIn and I see how many messages she gets in a day like I understand but she was like there's something about you that made me want to talk to you and like that's kind of like how the process started I started off as a contractor and then worked my way to like clinical pharmacy manager and then about six months ago I was switched over to chief of staff.

So I do a little bit of everything I see patients, do the marketing. Just a lot of the day to day operations and we're currently working on building our like products or a little EHR right now. So it's been a fun, wild ride at Perfecting Peds. 

Tovah Feehan: It's grown really fast. 

Brianna (Bri) Miluk: That's awesome though, because I feel like as, you know, an SLP who is more, who's in the outpatient or in the community side, like it is [00:06:00] very rare that we get the interactions with the pharmacist or that the, even like, not just us reaching out to the pharmacist, but the families even being aware that they can have a conversation with the pharmacist that they're working with now, because I think it is one of those things like they were in the hospital and it was so closely tied to the team that when they leave, I feel like sometimes when I tell families like, oh, you know, we, I know your child's on this medication and you feel like it may be affecting X, Y, Z, like have we talked to the pharmacist about it, or like, I'm having trouble getting my child taking this medication.

Well, did you talk about, could we add flavoring or could we use it in a different form or could we, and like not even being aware that that's the conversation like with the pharmacist that we should be having versus like going back to their, you know, pediatrician to ask that question. It's like, well, actually the pharmacist is definitely the expert in this situation.

Dr. Marry Vuong: I think it's like a cultural thing too, just because in this country we're used to like doctors prescribing and everything just coming from the [00:07:00] doctor. Whereas in other countries, like I went to a conference it was funny enough, a conference in Africa during pharmacy school and just the model in different countries is interesting.

So in England I think even to just get like a simple Tylenol or something, you have to see the pharmacist and the pharmacist has to like go through the check boxes. So it's really interesting now with Perfecting Peds because we've built this relationship with a lot of our families where if like one of the caregivers knows, oh, we're starting this medication.

They'll reach out to me for an appointment and then they'll tell me like, we want to start this medication. Can you check all the boxes to make sure it's okay? So like with my pediatric pharmacist brain, I'm thinking, is the dose okay? Is it indicated? Is it safe? Will it be effective? But then also on another level, does it interact with their medications?

Does it interact with their diet? Because that's something we're always asking. Like what kind of formulas are you on? What kind of consistencies? Like what's your diet like? If they have feeding tubes, if that interferes, if it'll be like given via g tube or j tube. And then we also think about pharmacogenetics.

So we do pharmacogenomics panels on [00:08:00] almost all of our patients. And then I also, always check it across that. So it's like when a parent comes to me with one question, there's like 10 different check boxes that we will go through just to make sure that everything's okay. 

Tovah Feehan: Is pharmacogenomics, I'm not even gonna say it right, but is that the way that you metabolize medication? Okay. So Jena, when I first met her she was actually helping me with my mom because my mom is on like a million different medications. And one of the questions that she had me ask her provider was like, have you guys looked at how she metabolizes these medications? Cause we just could not get things to balance out for her.

And it was a game changer, but I don't know how often, how often is that really being done in, in pediatrics? And can you explain a little bit more about what it is for people? 

Dr. Marry Vuong: Pharmacogenomics is a pretty simple panel. It was actually, it's like, it's cutting edge, and it's new right now. Everyone's trying to like make it just the standard of care, but Cincinnati Children's is actually like the pioneer.

I think they started their [00:09:00] program in 2005, and basically what it is, is it's usually a cheek swab where you're able to gather genes, and then it gets sent off to a lab. The lab will then check the genes against like the typical genes that would break down medications and it'll tell you like you will break down this medication faster than the average person so you'll need a higher dose or you'll have more side effects to this medication because you break it down slower so it'll sit in your blood for longer so it really just brings together like personalized medicine and I honestly love that we do it because it it is really cool to have this little pdf and it's kind of like you're 23 and me like your little personality test of this is how medications work with my body.

Brianna (Bri) Miluk: That's really cool. And this is like this is me obviously not being a pharmacist, but that makes me think of how like some people metabolize like caffeine really quickly and can drink like multiple cups of coffee a day and then there's like me who drinks one and is like I'm good till midnight. Like it just like [00:10:00] stays in my system.

That's why I don't drink coffee but I feel like that's like a a good comparison for for people and because that like the way we metabolize like so many things is very different that it's wild to me that like it took until 2005 for that to even be a conversation because like, of course, if we metabolize like foods and things like caffeine and different things differently that like medications should be part of that conversation too.

But I also think other side note is that knowing that like they started these conversations in 2005 and we're now in 2024 and it still isn't like the standard of care everywhere just shows how long it takes for like research to reach practice and for like things like that to happen. Which is just a whole nother interesting conversation, but you know, it's, it's exciting to know that that's, that's coming about and that you all are using that with a lot of your patients because I could see that being just such a game changer for some.

Tovah Feehan: You actually brought up, like, an idea in my head. I'm like, I wonder if there's [00:11:00] a panel out there that looks at how you metabolize different foods. Because I feel like that would be really interesting to know as well. 

Brianna (Bri) Miluk: Yeah, for sure. Cause there could even be some, like, cross interaction there, right? In terms of you're like, okay, make sure to take this medication with the food.

Tovah Feehan: Ooh. 

Brianna (Bri) Miluk: *Talking at the same time* Metabolize one at a different rate than the other, like how could that potentially be? 

Dr. Marry Vuong: I was like, let's open a lab. 

Brianna (Bri) Miluk: Yes. 

Dr. Marry Vuong: We have plenty of q tips, we can, we can gather our cheek swabs. 

Brianna (Bri) Miluk: Yeah, we'll just start by swabbing each other and then we'll go, we'll go from there. 

Tovah Feehan: And it's covered, too, by Medicaid, no?

Dr. Marry Vuong: Yeah, it's covered in some states mandate it. So in Pennsylvania, it is, I believe, one of the mandates that everyone should have it. And like the hospital where I worked started a pharmacogenomics program as well. And they wanted to make it the standard of care. So they were hoping that like by the time the program was like up and running, that every baby born or like any be any child admitted would have it already set and it would be a part of [00:12:00] their like just health record like this is what it is I think an important thing to note is that that is cool to have it like when you're born to have the pharmacogenomics panel, but your genes kind of change after you're two when you're fully developed so then you would have to be like re swapped at that point.

Tovah Feehan: Wow *Talking at the same time.* Yeah, I would never guess that Yeah. 

Dr. Marry Vuong: I think everything matures by two so then you have to like redo it. 

Brianna (Bri) Miluk: Okay, okay. And is this something that, like, say a family needs to get it redone after the age of two, is that something that they can talk to their pharmacist about? Is that something they talk to their physician about?

Is it something that they like go back to the hospital for like who typically is running those tests or labs like is it something that's just done like they just go outpatient to see their provider and they can send it off or how does that part work? 

Dr. Marry Vuong: I think it depends on I think the state that they're in just because like some people are more informed about it than others but I think [00:13:00] it's just a matter of asking somebody and then somebody will lead you to the right place. And it depends a lot on like the different collaborative practice agreements and things that people have based on who can order it But I would ask your PCP and have your PCP, like, kind of triage. 

Brianna (Bri) Miluk: They'd probably be able to guide that, yeah, the, the connections of care.

Cool. Very cool. 

Tovah Feehan: The other crazy thing that I learned from Perfecting Peds is how frequent med errors happen. 

Dr. Marry Vuong: Yeah, it's it's kind of scary. I mean, but it's not that it's the basis of our business but it is like we're here to help prevent med errors and you'd be surprised just how many errors can happen just from like not knowing like not knowing what things are used for so a lot of the parents that we like talk to aren't super health literate.

So just like nobody took the time to just explain to them like they're different inhalers. So I think I met with a patient once that they were taking three kinds of inhalers and they were all the same thing because the parent didn't know that the nebulizer, the, and then [00:14:00] the two inhalers they were taking were all like steroids.

So like at home they were getting one, one inhaler. It was like blue, and then at school they were getting like the orange inhaler and then at night they were giving the nebulizer and it was all the same like variations of drugs like budesonide fluticasone like all things that did the same but it's just like nobody took that time to like just explain.

Oh these these are all the same we're switching you from a nebulizer to an inhaler. Make sure to use the orange one and throw away everything else before you start it and then there's no communication to the pharmacy so they're continuing to fill it and then there's no communication back to the office so they're continuing to refill it so it's just like a swiss cheese model where if someone just took a second to explain it would have prevented this med error and like one of the side effects of taking too many steroids is like growth suppression but then there's also thrush so then this child mom was like yeah i don't know why his mouth is always fuzzy.

It's like this weird white fuzz all over it and it was simply because like there was a med error that [00:15:00] happened because there was some like leak in the communication, but it happens quite often. It's actually a one in three chance of a med error happening in a pediatric patient. And it kind of makes sense because if you go back to like what I originally said, not many people have that much education on pediatrics and it's kind of scary because we are all pediatrics at one point we all grew up and we were all children.

So like in school I never really had the chance to have like a pediatric elective or class because my school didn't offer it but they did offer like a rotation block so I did take like four rotations in pediatrics and that's where I really like gained the love for it but most people aren't fortunate with the with like that much training in peds and then in like medical school and stuff you don't really get I think maybe people get like a lecture or a block but in the grand scheme of things it's a tiny portion of their education that's devoted to pediatrics and if you really wanted to learn more about pediatrics you'd have to specialize in it so it's just such a very like underserved population so there's not much research in [00:16:00] it I think we found that 85 percent of indications for pediatric medications are off label, which is a little bit scary as well.

So that means that like it wasn't studied for a pediatric patient. It was extrapolated off of adult data. So that's like another place where there's a lot of med errors and then pediatric medications are just so different. So for an adult, you hand them like one tablet and it's fine, but for a pediatric patient, everything's based on their weight.

So you're really calculating each individual dose. And like how I would always explain it to my residents in the hospital was like, okay, you are admitted for an infection I'm just gonna give you this IV bag or this one tablet and that's your dose but for a pediatric patient that IV bag had to be further diluted it had to be calculated and drawn up to the exact weight of the patient so it would come in a patient specific syringe every day or at the same cap, like if it was an oral medication instead of just being able to give one tablet, you would have to either find an oral solution or like compound suspension [00:17:00] or crush a tablet and have instructions on how to like dilute and it's like a patient specific dose. So it just takes so much more detail. So with all those little details, there's way more room for mistakes.

Tovah Feehan: When you're talking about crushing a tablet and the different things, I don't know if other people would be interested in this, but like, I geek out about this and want to learn more. When, when families are saying like, oh, we can't get this medication because it's compounded. Or, I just talked to a friend this morning and there's a little girl this little girl is, in Hem Onc and she's being treated for cancer and she had to stay in the hospital longer because they couldn't get her, her medication was only in the hospital.

She couldn't get it locally outpatient. They would have had to drive to like Long Island and I'm in New Jersey outside of Philadelphia. So just things like that. Like why are certain medications not available? Why do certain ones have to be compounded? 

Dr. Marry Vuong: Oh, a lot of it is because of the research. So there's not that much money in like funding [00:18:00] pediatric research. So a lot of times with like drug companies, it's easier to get something to market also for adults so that's probably one of the reasons why it's not available in an oral solution. You have to go through, like, way more parameters to make sure it's stable and that it, like, stays fine. There's refrigeration and all these, like, storage things that are so different with liquid medications.

And then one of the reasons why she probably couldn't get it at home either was because it's a chemo so it's probably hazardous so there's like all these different parameters on like nursing requirements and like requirements for the family if they were to give it so sometimes that that just ends up being like what happens and like I always freak out because like some of the kids are on seizure medications that are also hazardous, so then sending them home with the right instructions on how to like on how to manipulate it like let's say they need to cut it well, the family needs to know that they have to wear gloves. They have to make sure that they like they are protecting themselves because some of these medications can be like teratogenic or [00:19:00] can be carcinogenic if they're open so like just little things like that are good counseling points. So it's always great to just like have that have that pointer to ask a pharmacist before telling a patient to like manipulate a medication. 

Brianna (Bri) Miluk: That's such, like, that's such an interesting it's just so interesting to learn about, but it also makes me think, like, going back to our conversation about, like, health literacy and things like that as well.

And so you have to, like, be very, very clear and like, you know, probably provide education in multiple different ways to make sure that a family like truly understands how to manage that medication, manipulate that medication and like understanding that like, this isn't like, oh, well, we're just in a hurry today, so I'll just like, you know, open it and not worry about like, no, no, no, no, you have to go through that whole process.

And then it just makes me think about also like for some of our families, how how just the added difficulty and added burden of some of those things as well that they then have to [00:20:00] use in their preparation of their day. 

Dr. Marry Vuong: Thinking of like health literacy. We also think of like social determinants of health. So a lot of times the compounded medications, ironically, are so expensive, or because it's compounded the parents have to pay out of pocket. So sometimes, like as a clinician, you have to see, you have to think like, okay, their hospital stay is covered. But this medication would cost a lot of money outpatient, like what should we do for this patient?

So it becomes like an ethical thing sometimes too, where you're trying to help them afford it. Unfortunately, compounded medications usually aren't covered by insurance, so then as a pharmacist, you kind of have to get creative, like what are ways the family can compound this at home? I actually had a patient with h pylori the other day, and insurance would not cover the oral solution for the Flagyl. And like, Flagyl, if you've ever had it, is the worst tasting medication ever. It just tastes like metal. And the oral solution is a little bit better, but it was 600 dollars. The family clearly could not afford it. And we had to get, [00:21:00] like, really creative with that.

So we had to, like, think of ways to, like, crush it, so that it was more, like, palatable for the kid. So one of our tips and tricks with that is chocolate usually is okay, and it doesn't interact. We would stray away from a lot of dairy because dairy interacts with a lot of medications. And then the other medication that insurance wouldn't cover for them was like nexium or esomeprazole.

That usually comes in packets, but insurance would not cover it. So then I had to get creative and I was like, wait, I think maybe we can make them like a cheaper solution with like omeprazole. So like they could put the omeprazole sprinkles into applesauce and give it that way. If she doesn't tolerate that, then you could also tell them we, we could also tell them to dissolve it with a little bit of sodium bicarb or baking soda.

And that helps degrade the pellets and makes it into like literally a liquid. So just like knowing those little tips and tricks, I think will help in those situations where the family's stuck at the hospital because things aren't covered. [00:22:00] 

Tovah Feehan: That makes me think of the patient that I asked you about, Marry. So I had reached out because I had this little guy who he has an NG tube and he's on thickened liquids and very quickly, once he was on thickened liquids, he started taking much more PO because, wow, he wasn't aspirating. Cool. So we got to a point where we could try to pull his tube and see how he would do orally because he was taking, a lot of days he was getting that full volume.

But the meds were the tricky part because the meds were still going through the tube and we didn't know how to, if we could thicken the meds or what that would look like. And so I had reached out to you and you had given me really, really helpful advice about those two meds that he was on and, and how you would recommend thickening them. And one of them was Omeprazole. 

Dr. Marry Vuong: Yeah. I feel like there's so many creative ways, but you kind of have to do like, do a deep dive on things. We definitely never recommend like, commercial thickeners, like Simply [00:23:00] Thick, and things like that for medications because they can alter the way that these medications are absorbed.

But most often, like, food, like applesauce is usually a good one. I've done a lot of meds in ice cream, so one of my favorite things that we've done was for an autistic child who was so scared of the toilet that I think he didn't go to the bathroom for, like, two or three months. So he was literally like filled to the brim with like hardened stool but he hated the way all the laxatives tasted.

So one of my attendings was a resident I think at Boston Children's and they did something called the chocolate bomb and we didn't, I think we asked him and he didn't like chocolate ice cream, so we had to do a vanilla bomb. So what we did was that we mixed Lactulose, which has like kind of a minty flavor, into the vanilla ice cream.

So that's like kind of the osmotic, like the wetting laxative that would make his stool softer. And then we took Santa chocolates and we sprinkled them up top, so it kind of like looked like the sundae. And because it was like masked, and it looked okay. [00:24:00] He ate it and he actually was able to stool. So a lot of times we find like really creative ways like that or like mixing things in the formula.

I've had to like mix phosphate binders into formula, like decant it to take out the gel and like give it that way. Just for a patient that could only tolerate it through the formula. So we've had to like, find really creative ways, but it honestly makes the job so much more fun because I, like an adult, I'm pretty sure we're not making chocolate sundaes to get a child to poop.

Brianna (Bri) Miluk: I love that. And I feel like it shows too, like, as you know, the, the feeding therapist that's working with the kids, like exactly why we should encourage more collaboration with pharmacists as well as being part of that interdisciplinary care team, because like I wouldn't know which ones would be okay.

Like you said, like dairy, oftentimes you hear is like, okay, a lot of meds can't mix with dairy, but like sometimes they can, you know, depending on which one it is and which like thickened liquid, I was thinking Tovahh when you brought that up right [00:25:00] away, I immediately thought about the use of thickeners with laxatives.

Cause a lot of times we have kids that need both, but you can't mix like Miralax, for example, with a commercial thickener because a lot of times then it loses its thickness. It kind of takes away from, we're trying to make their swallows safer, but we also don't want them to be constipated. And then by mixing the two, it just, it just doesn't work that way. And so we have to be, find other creative ways for it as well. 

Dr. Marry Vuong: I feel like at the same token, like a pharmacist has no idea about like the consistencies, how the child is swallowing, like all of those like very important details. And if you think about how important swallowing is in your life, like you have to swallow your food, which is vital for living.

You have to swallow your medications, which if you're super chronic kid, also vital for living. Then you also have to swallow your saliva. So that's like another thing in the ho- like, in the hospital and, and in Perfecting Peds that I see is that a lot of these kids aren't able to, like, swallow their saliva.

They're not able to swallow [00:26:00] their meds, so then that just gets to the root cause of everything. Like, this kid is having more seizures than he's aspirating because he can't swallow properly. So that's where we, we call in our besties our SLPs. And that's something that like, I guess, was ingrained to me so much in the hospital.

Like, swallow study, swallow study, swallow study. So I'm always asking like, how is your child swallowing their medications? Do they need a feeding tube? Have they been assessed for a feeding tube? And that's just like the population that we deal with. Almost like the majority of them have swallowing issues.

Tovah Feehan: Bri knows this about me, but when I get really excited, I like I'm like, I want to interrupt, like I want to interrupt and chime in and like the questions are just like piling on in my brain right now. I'm so excited, but she taught me how to like mute myself and be quiet. 

Brianna (Bri) Miluk: I was like, Tovah, mute yourself sometimes. Just, just so that we can all get through. Because otherwise, I'm sure you know, Marry, with like podcasts and stuff, it's like if we all try to talk at the same time, [00:27:00] the recording is like, nobody can actually hear anybody, what anyone said. 

Tovah Feehan: Wait, did I do it? Did I interrupt? 

Brianna (Bri) Miluk: No, you didn't. 

Tovah Feehan: Oh, good. Okay.

Brianna (Bri) Miluk: I'm just thinking about the conversation we had. 

Tovah Feehan: Yeah, I, yes. I'm my own worst critic, as I think a lot of us can say. But so, when you were ta- I have a list. But, when you were talking before about how, you know, most residents in medical school they get one, course in it, and even going to school to be a pharmacist. It reminded, and the research and how you have to extrapolate from adult literature, it reminded me so much of what we're doing as pediatric speech pathologists in the feeding world.

We're extrapolating so much from the adult literature. A lot of times I think it's changing, I really hope it's changing, but people have pediatric feeding as an elective, or when I teach dysphagia, it's half adult, half peds, because I want to give fair coverage to both, and there's only one course in all of graduate school for it. So I find that really interesting, and I feel like we could help elevate each other. [00:28:00] 

Brianna (Bri) Miluk: Yeah, that's so true. I think I do like to like, you know, think that we're moving in the direction of more universities prioritizing having those courses, but I do know I feel like majority right now are still electives.

There's some that have required, but majority is an elective. And then that's even like, if you then were to get like a rotation with it, you know, that's, that's a whole nother layer to it as well, but like my dysphagia course was like a week or two of peds and the rest was all adult. But I think the, the research part, like we can definitely relate to that.

It is very heavy in the adult population. But I think that's also where like, Marry, you were talking about like that kind of is what makes it fun is like how you have to problem solve through some of these things that like you're not going to see that in the literature, but it is kind of fun to be able to like, take what we do have and be like, okay, now I have to think through this critically and how does that actually apply to my patient?

Like the, a lot of times the research [00:29:00] I find that like the method that they went about something is like, well, that won't work with a kid because they just won't do it. So like, I see this outcome and that makes sense, but like I can't use that same method because the kid's just gonna not. So how do we, how do we come to that same result with using something similar, but in a different way? And that's like one of my favorite things about pediatric feeding and swallowing is because we are constantly, every single kid, we have to think through it. Like, So critically because of that, that.. 

Dr. Marry Vuong: So an interesting layer with kids, too, is that you're not only dealing with the patient, but you're dealing with the caregiver, too. So it's like a whole other layer. Like, I understand if it won't work for the kid, but it also has to work for the caregiver. So does it work with their work schedule? Do, like, are they able to, do this are they able to somehow get their child medication in the middle of the school day? Like does the nurse allow it like what permissions do you need?

So it's just like it added it adds a whole other layer. Like you can't just be an adult with [00:30:00] meds in your pocket. You have to go through nursing. The nurses have to be educated at the school and the parent has to be able to like refill this. The pharmacy has to be able to split out the doses so there's home doses and school doses. So it adds a whole level of complication. When I think of it, it takes very special people to work in pediatrics. It takes like a lot of grit and creativity. And that's honestly why it's the best.

Tovah Feehan: I would agree. I experienced it though, like I was mentioning my mom, and I feel like it is, there are a lot of similar challenges with adults because Bri gets like long voice notes from me if I have a rant and I was so ranty when she got home from the hospital a couple weeks ago because there were med errors.

There were a few doses that were off. There was one medication that's over the counter. So my dad looking at the list when you're talking about health literacy, he's like, well, that's not important, but it was so important. We just didn't know. We just didn't know. And, and talk about health literacy.

Like I work in healthcare. I didn't know. I don't, I don't know about medications, especially for the adult population. [00:31:00] So having someone like you is so, so valuable. And I was curious too, because you mentioned there's like, is it 1,900 in the country you said? So, is that different than when you talk about board certified pharmacists, like, I'm sorry, this is so ignorant, but like, if I go to like Walgreens or CVS or Rite Aid or whatever, the pharmacist that's there, is that similar? Is that the same? That's different schooling or different? Okay.

Dr. Marry Vuong: It's different. So the pharmacist that usually you'll encounter, like at a community pharmacy, typically, will do like the four years of like a bachelor's or two years. Some people don't get a bachelor's they just do prereqs then they'll go to pharmacy school, which is like a doctorate. So that's four years that like non-negotiable you have to do and then after after that you can go and work in a community pharmacy. So that those are the people like those are the kinds of pharmacists that you'll see outpatient if you want to work in a hospital, then you would do residency.

So it's one to two years in a hospital where you're just like straight up learning for two [00:32:00] years. And then board certification is granted to you after three years of experience. So you're able to sit on the test after three years, but you have to like study and pass it, obviously. And then you have to maintain it.

So you have to maintain all of your like education credits and everything every few years to keep that status. So your your typical like retail pharmacist would just do the doctorate like a hospital pharmacist would do like the two years of residency, but someone who's board certified had to like take another step. So the 1,900 is just the count of the board certified pediatric pharmacists in the United States. I'm sure that there are more pediatric pharmacists, but I don't know how to count them. The only way we know is by looking up the board certification And it's voluntary.

It's not like for doctors for like physicians, they have to be board certified in order to practice. Right now, because I think clinical pharmacy is more of a newer field it's like optional, but I see that in the future, they'll probably need to be board certified in something. 

Brianna (Bri) Miluk: I [00:33:00] can see the importance of something like that from like a regulation standpoint, from, you know, making sure that like, there's some, oh, what's the word I'm looking for? Like regulation is just popping up again, but like accountability to, to the, the education and the maintenance of it and all of those pieces together. And I think we see very similarly in our field in maintaining that, that licensure or certification to make sure that there is some consistency in, in what we're doing. 

I think for, for a lot of the patients that we work with where we see, at least for me, the, a lot of the breakdown is managing medication, specifically seizure medications for kids and how that impacts like [00:34:00] arousal. It can impact alertness, it can impact appetite, it can impact like, you know, nausea, feelings of fatigue, and kind of all of those different pieces. And then additionally, you have the child who maybe has seizures who is also requiring thickened liquids and or tube feeds and kind of managing those pieces.

So I would love to just kind of talk through like I guess like I feel like so ignorant because I'm like, I don't even know what to ask if that makes sense. You know, like maybe we start out with like just part of that. So talking about seizure medications just in general, in terms of like some of the side effects and how we can maybe, for example, I think of the appetite as probably being one of the biggest ones, appetite and arousal being kind of the two biggest areas where I think about safety standpoint and how, you know, you would even potentially think through a case like that. 

Tovah Feehan: And I just want to add one of the reasons why we were talking about this population so much is it's because one of the [00:35:00] ones that we see the most variability and the most challenge when it comes to being medicated correctly and how much it impacts our ability to help.

Brianna (Bri) Miluk: Yeah, because it's a big risk to benefit, right? Like, it's like, well, if we change this medication too much, we put the child at an increased risk of more seizure activity or that, you know, versus like, do we deal with the, okay, let's just come up with other ways to arouse them before a meal. Like how to.. Anyway, it's a very nuanced conversation, obviously. I'm not expecting you to have, like, Oh, well, this is what I would do with every single kid. You know? 

Dr. Marry Vuong: I'm happy you asked me about seizure kids because that's honestly my bread and butter. My heart is in neurology and that's, like, what I specialized in. So that's like the perfect question to ask. I think along the lines of appetite, there are a lot of seizure meds that do cause reduced appetite.

So that's where it becomes a little tricky so right off the top of my head Cannabidiol or Epidiolex is one of the [00:36:00] ones which you'd be surprised because when you think of like marijuana you would think that it would cause more of an appetite stimulation, but because it's like the cbd part of it It actually causes suppression.

So a lot of kids when they start Epidiolex end up like being less hungry, and they end up losing weight. The other one is Topiramate or Topamax. That one definitely causes, like, weight loss as well, but then we kind of try to use it if the patient needs to lose weight. So you, you kind of try to double dip in that way.

With the, the appetite, like, it's kind of hard because the seizures or appetite, like, what, what do you pick in this situation? And ethically, usually with appetite suppression, we would add on like something like Cyproheptadine, something just like really benign that'll help them stimulate their appetite.

Or you can add on a seizure medication that will, like, that will help. Or if they have like additional psych problems, then like adding on an antipsychotic that stimulates appetite might help as well. So in [00:37:00] those situations, I always. weigh out the seizures first just because, like, time is brain. The longer they're seizing, the worse it is for them.

So we kind of just try to add on or double dip on different medications based on what their other conditions are. I'm a big, like, double dipper or triple dipper, quadruple dipper, whatever I can do. So, like, if the kid needs appetite stimulation, they also have migraines, delayed gastric emptying, and they need help with sleep, Cyproheptadine would be like my drug that could help with the appetite suppression, but then help with everything else.

And that way we're only adding one instead of four to help with this problem. Along the lines of alertness. That's another really hard thing with these kids, because if you like run any of their meds into a drug interaction checker, it's going to tell you CNS depressant all the way down. All of these meds, unfortunately, are made to stop seizures and they're made to suppress the brain because a seizure essentially is like over activity of the brain.

So one of the tactics I like to do with that, especially if they have the issue of [00:38:00] insomnia, is doing larger doses towards the end of the day. So we're so used to giving like the same dose, like let's say if a medication is given three times a day, you give the same dose normally three times a day, like 10 milligrams TID.

Instead of doing it that way, a good tactic is to like gradually increase. So let's say we'll do 2. 5 in the morning, five in the middle of the day, and then 10 at night and that way you're giving the same total daily dose but then in a way that it forms more naturally to their body and like the sleep wake cycles And then they'll be more alert during the day.

I also will try to consolidate things as much as possible. So if it is something that can be given twice a day or once a day instead of like three times a day if it is something that makes them sleepier in, like, in the beginning of the day, I'll try to just, like, give it at night if I can. So it's, like, a lot of just, like, playing with timing and, like, knowing the pharmacokinetics and the onset of things to make, like, the perfect custom schedule.

I had a kid, actually, that was losing a lot of weight. He was a [00:39:00] foster kid, just adorable, was losing a lot of weight, and the caregiver asked for, like, kind of an emergency meeting with me because she's like, he's not feeding, he's like very irritable. But then he's not sleeping at night because then he is so riled up in the middle of the day that he's not taking his nap and it's like this whole slippery slope and he's just not eating because during the day when he's supposed to be eating, he's like riled up trying to fight his nap.

So then we changed his Gabapentin so it was like a low dose in the morning so he'd be awake for his morning feedings and then kind of a higher dose around naptime, so he'd get sleepy, wouldn't be riled up, would wake up for his like, nighttime feeding, and then would be so tired by the end of the day that he'll get his, like, nighttime dose and fall asleep.

So it's just a lot of just, like, communication and trying to find what fits best, and that's, like, something that we do at Perfecting Peds. We try to see the patient as a whole so we're not just looking at, like, do these medications work and, like, with the dosing and whatever. It's, like, does it work with your life is our biggest [00:40:00] thing. 

Brianna (Bri) Miluk: I love that because I feel like as like an SLP, a lot of the times I'm thinking about or when I'm collaborating with like, for example, a dietitian, a lot of what we're doing with like tube feeds would be like timing, schedule, volume. Like, could we do less in the morning, more in the evening for catch up if we need to and kind of modifying that.

And it's the same thought process. You know, we don't think about that with medications because you're so right. Like I feel like any time I've ever been prescribed something that they're like, you know, take this three times a day. I automatically divide it equally three times, you know, without even thinking about how like, well, wait, it maybe doesn't have to be that way depending on what the medication is.

But also I love that you talked about like, you know, doing like a two for a three for a four for and kind of thinking about some of these medications of like what we may consider like a side effect in one kid could actually be a benefit in another and thinking through like [00:41:00] how we can you know use one medication for a majority benefit. I love that. 

Dr. Marry Vuong: Yeah, I'm always like a less is more kind of person like if I can reduce the amount of medications and reduce the amount of things you're doing throughout the day because I can honestly tell you I had to take a Medrol dose pack recently and I couldn't remember because it was like take this one with this this and this and it was like seven times a day when it's so complicated like that. Like I'm a pharmacist I know that I need to take it. I know like the reasons behind it and I couldn't even take it like I try to just simplify it as much as possible. 

Tovah Feehan: I love it. I love the art of what you're talking about. It's like you're speaking our love language right now. *Talking at the same time.* Yes, the critical thinking and how it can become so siloed with medications, just like with dysphagia or pediatric feeding disorder, it can happen for so many different reasons. And sometimes we're operating with our tunnel vision instead of looking at the whole picture. And I'm just curious though, because usually if I think about, you know, for example, like a reflux medication or motility or apoptosis, it's typically [00:42:00] coming from a GI doctor or if it's something like inhalers - pulm. So how do you do you have any tips for us for how to open up dialogue with providers and pharmacy as a team? 

Dr. Marry Vuong: Open communication. A lot- I can't say that it's always perfect because I do feel like sometimes people get offended, but I always try to frame things like a question and I try to make it like a conversation.

So I'll be like, hey, what do you think about this? Like, how about we do this? So I try to do that and like form a relationship. But I can tell you that we're super open to like talking all the time. We love collaborating. I can't say that it's the same with everyone, but it just like trying and reaching out. I feel like doesn't hurt. Like the worst someone can tell you is no. But then you just try again with someone else. 

Brianna (Bri) Miluk: I feel like that is, it's honestly like, hopefully like listeners feel this way as well. Like it's very refreshing to actually know that like we have another point of contact when talking about medications because I [00:43:00] totally like, understand with a lot of the physicians that I work with, like they don't have time to sit down and have the conversation about like, hey, I'm noticing X, Y, Z with their medications.

They may prescribe the medication, but like, we can still open up the conversation with the pharmacist on some of that as well. And so sometimes having more of like, I'm thinking about like, if I was to call the GI, like Tovah said, and say like, hey, like, you know, this, you know, you're the prescribing provider.

I wanted to bring up conversation like, what do you think about me having a conversation with the pharmacist about, you know, managing the medication and the timing of the this and the that? And like, obviously one, we, ideally, interdisciplinary, we want everybody on the team. We want everybody having this conversation, but also recognizing like where it might play a role or who might play a better role in certain conversations.

But I think that that could even like open it up more because sometimes, like, at least I will find, like, it's so hard for me to get a hold of the physician sometimes. I end up talking with, like, their [00:44:00] nurse or, you know, sending messages, like, back and forth, but, like, not as clear a line of communication as, like, going directly to the pharmacist and opening up that conversation there as well.

Dr. Marry Vuong: Yeah, it's not really it's like I feel like we're all equal in the fact that we all have our specialties we all have things that we're experts about so we should have mutual respect for everyone. So just like not really going to someone because you think that like the other person would respect them more but just because maybe they have like an in with the office or something or they figured out like the best way of communication I think that like the respect should be equal upon everyone, but it's just knowing how to, like, work the system.

We have, we, like, love feedback, and we love, like, learning from other disciplines what they think is best, so we do have, like, some physicians on staff with us that work as consultants, and they told us, like, a trick for you is that physicians love faxes. And faxes with checkboxes. So if you ever have any questions, you can fax their office with like a checkbox, yes or no, and like a signature [00:45:00] line.

And honestly, from like a physician's perspective, they say that if they have like a busy day in the office, they'd rather have a stack of paper that they could check yes or no, give to their secretary, the secretary faxes it back versus having to like type and respond to an email or a text or something.

So just learning the best way of communicating, I think will break down a lot of barriers. But then also just working and having like a team based approach to communication, because sometimes it might be better to go on with something together, like, and be like, hey, we both think this, like, what do you think?

Tovah Feehan: I'm thinking about aerodigestive patients where I have another baby right now, where he's on a PPI, he was on Lasix and he kind of outgrew the dosage. So he has breathing difficulties, was born premature. And it's like, that would be the perfect scenario where it would be so helpful for GI and Pulm and myself to, and a pharmacist to meet together to talk about, well, this is what's impacting his swallow and his breathing and is exacerbating his reflux and there [00:46:00] might be a way to consolidate or a way for us to help each other help him.

Dr. Marry Vuong: Yeah, I feel like there's so many and like, I guess being being spoiled in the hospital where everyone's in one building, in outpatient it's so different where you're trying to like get a hold of everyone but then just having like a quick Teams call like let's have a five minute powwow about this patient I think would be nice to just bring everyone into the same room.

Brianna (Bri) Miluk: Yeah, absolutely. So kind of shifting from like us reaching out and knowing like I'd love to talk more about like tips for to give caregivers on how they can best advocate or like questions they ask because I feel like for me, a lot of this is helpful, right? Because it's like, well, I don't even know what I don't know.

So how do I ask the question? How do I frame the question? So kind of just opening up tips for to share with caregivers about advocating for, for their child and questions to ask when they're maybe thinking about their, their medications for their child. 

Dr. Marry Vuong: One of [00:47:00] our caregivers actually like we had to, it was a hard sell for her. We had to, like, she was like, you have five minutes to prove yourself to me. And I was kind of scary. She's like, I have three chronically ill children. Like I don't have time for someone else at the table. Like if you want to be part of our care team, you have to prove yourself. So we were able to prove ourselves with one and then she gave us all three.

And she now actually works for us. And she's a patient caregiver ally. Love her to death. But the thing that she taught me and that sticks with me on a day to day basis is to stay curious. So, just having that in your head as a caregiver and knowing that yeah, your doc, the doctor went to X school, the pharmacist went to X school, they have all these certifications, at the end of the day they're still a human and they still should like be very curious and should be constantly learning.

So just having that in the back of your mind to empower you to ask the questions. Nothing, no questions ever, stupid question, like, if you have a question if a med can be crushed and given via Jtube, ask it. If you, if you have questions about different interactions, if you [00:48:00] have questions about something that you think might be better because you read about it or your SLP gave you a great tip about something and you just wanted to, like, check it out ask like it doesn't hurt and like empower yourself by asking empower yourself by researching like get a second opinion get other opinions reach out to other specialists like I think that medicine should be so fluid and it should be more of a conversation than an order that you should never really be scared to ask.

Tovah Feehan: And it's a team. So I love that you talk about empowering caregivers and also the curious like for us as healthcare providers as pharmacists to be curious because they're the ones who are with their child who are going to notice the side effects or how it's helping or not helping or when I give it at this time it helps but you talked about later in the day or earlier, vice versa. I'm noticing increased secretions or whatever it is that, that we're also listening to them as caregivers because they're the ones in the trenches who are going to have a lot more detailed information about, about how it's [00:49:00] interacting. 

Dr. Marry Vuong: Caregivers are honestly my favorite. Like I hate when they're, they're dismissed in the hospital or they're dismissed in the clinic because they're seen as like the crazy mom who always has a million questions, who challenges everything. But that's that's, that's the mom that cares. Like, that's the mom you should be listening to. That's the mom that knows their child better than anyone else.

They're in the trenches when nursing calls out. Like, they're the ones giving, administering, doing everything. So, like, that's the person you should be listening to. And, like, that's kind of the relationship that we try to build at Perfecting Peds. We try to make it so that we're not only a part of your care team, but we're, like, one of your best friends.

So some of the moms, like, I will see them and they'll be like, can I call you for five minutes really quick to, like, run this by you because I just need to like say it out loud and like see if it's okay and I'm like sure like it always like stay humble and just like always be willing to like listen and bounce ideas back and forth because like what you think and what you learn in school might not always be what's best for the patient it's just a like communicating and like listening is, I think, one of the [00:50:00] most important things.

Brianna (Bri) Miluk: Yeah, I feel like that, and like, the whole point of that, right, like, I'm, I'm the same way, I love the caregivers that are like, what about this, what about that, what about this, what about, like, constantly asking, because ultimately, like, that, like, my main goal is to come up with something that is, like, functional for that specific family unit.

And like that child and that caregiver and trying to reduce any added burden as much as possible while still promoting progress with the child and that open conversation is what leads to that. So like ultimately like those conversations answering those questions, having caregivers, like any caregivers listening, ask those questions because ultimately like that is what helps versus like, I would rather you ask me so many questions than be like, okay, that sounds good.

And it doesn't. And you go home and it didn't work. And it's not working out for you. And then like compounding that versus just like the open dialogue of like, okay, here's one suggestion. And a lot of times, right? Like, I think like you said, Marry, sometimes it's like, It can come off as like an order and [00:51:00] it's like, no, no, no, no, this is not like, this is a suggestion. It's a potential recommendation, but like you peel back the layers and you let me know what you think about that. If it's, if it's going to work or not. 

Dr. Marry Vuong: And if it doesn't work, call me and we'll troubleshoot it together. We always, I always try to empower and I try to give instructions like let's say like you have the Senna and the Miralax, the child's having too much diarrhea, but still they're full of like stool.

What do you do? And I try to teach them like too much diarrhea, so peel back on the Miralax. Too much cramping, peel back on the Senna. And we try to give them instructions where, especially if it's over the counter things, not really so much with like prescription things, they know how to like titrate and they are able to like empower themselves to troubleshoot. But we always tell them like, call us and we'll, we'll troubleshoot it together. 

Tovah Feehan: I love that. And even the fact that for caregivers to know that there are options, because it is one of those things where it can be, it's an order, it's a piece of paper and it has this [00:52:00] specific, you know, dosage on it. So even just for us to know that there's flexibility there, that there's room to, to make adjustments and that there, there are so many options is, is really powerful.

Brianna (Bri) Miluk: Yeah absolutely. 

Tovah Feehan: I think the only other thing that I was curious about that I feel like comes up a lot but it's not, you know, complex and it's not always chronic, is reflux because I feel like it's, it's always changing how we treat it and how long we're giving certain medication.

Brianna (Bri) Miluk: What meds are best versus not. 

Tovah Feehan: Yeah, and how they interact, how certain reflux medications interact with thickened liquid, like if we're doing an Enfamil A.R. thickened formula and how we have to be careful because it changes the [00:53:00] efficacy. And I, and I recently had a family ask about reflux medication, like, oh, we're not, we think it makes our baby nauseous. Which our babies, obviously, they can't tell us with words, but they're thinking it makes their baby not feel good. So those are, like, when it comes to reflux, just getting your take on that. 

Dr. Marry Vuong: With reflux, I'm in the camp of non pharmacologic. I am, like, out, my, anyone will tell you that I'm the PPI police. I absolutely am very much against long term PPI use because it's something that gets slapped on, probably, like, from discharge, from the NICU. And then it gets- it stays on, and then I see you when you're 21, and I'm just like, oh man, you've been on a PPI for like 20 something years. If you read the guidelines, PPIs are like drug of choice, but they should be used for a short amount of time, so like six to eight weeks, and then weaned off just because of all the side effects.

So there is like bone demineralization that can happen. One of my kids was on chronic PPIs and had like a fracture so we had to like take him off of that. [00:54:00] You also have like increased risk of infection. It depletes your, like, magnesium and B12. So I'm just not a fan of, like, being on something for so long that can be fixed with diet, medicine, like, with diet as medicine instead.

So I'm always in the camp of, let's thicken, like, let's try to thicken, let's try to elevate head of bed, like, let's try space out the like the hours between feeds and bedtime. So I try to really stray away from anything for reflux, but if they do need it, we try to do the lowest dose possible for the shortest amount of time possible.

And then I always try to look for other causes as well, because a lot of times we think it's just reflux, but can it be solved via like a fundoplication? Can it be resolved somewhere else, is it like another functional issue that's causing this? Like, I like to get to the root cause of things instead of like slapping on a medication as like a band aid for everything.

So like, even though I'm a pharmacist, I'm a big fan of like deprescribing and using like non pharmacologic things because non pharmacologic things [00:55:00] have less of a propensity for like adverse effects. And I think like the more meds you slap on, the more chances you have of like drug interactions and different side effects that you may not want.

Brianna (Bri) Miluk: I love that and I feel like it's so aligned with like the NASPGHAN guidelines when they came out with especially for infant reflux and really saying like hey, like let's let's start with like AR formulas or thickening feeds slightly so that we can see and then like you said Marry, I have also found just like in my clinical practice that if a child has reflux like after a year old, like still very significantly, I'd even argue like significantly after six months old there's usually something else.

causing it, like a food allergy or something esophageal, dysmotility, like, there's, there's usually something else versus, like, that medication really making a significant difference. And I've had it, I've had some kids that, like, the medication does help for that, like, short term, but [00:56:00] ideally we want to have them weaning off of it as well so we can kind of reassess whether there's, was a difference made or not.

Dr. Marry Vuong: And it goes back to like, just staying curious and like, wondering, like, what is it? Like, can I, can I continue to like, look further? Are there more creative ways or more beneficial ways to fix this problem? 

Tovah Feehan: I love it. I want to jump through the screen and hug you. 

Dr. Marry Vuong: I know, I, I kind of want to, I was like, oh, go visit Jena's.

Tovah Feehan: Yeah, so Jena lives really, really nearby to me. Like, I've run into her at the playground before with her kids but I didn't even ask where you live. 

Dr. Marry Vuong: I'm in Miami, so I'm, yeah, pretty far away. 

Tovah Feehan: I feel like me and Bri should probably like post baby. 

Brianna (Bri) Miluk: Yeah. 

Tovah Feehan: Once you have your baby, we should probably take a Miami trip. 

Brianna (Bri) Miluk: Yeah. We'll just go to Miami. 

Dr. Marry Vuong: For sure. Come on down.

Brianna (Bri) Miluk: That's awesome. Well, thank you so much, Marry. I mean, we, we love what you all are doing at Perfecting Peds. I think it's really, really awesome. And I also love that [00:57:00] like you all are starting to elevate the conversation as well of like pharmacists working together with feeding therapists so that we can really support continuity of care, improved, you know, quality of care with the kids that we're working with, because there are so many questions that we still need to be asking and there's so many things that we can do if we just open up that dialogue and we start to open that up to really help kids and looking at them from that holistic lens.

Dr. Marry Vuong: Oh, thank you so much for having me. This was so fun. 

Tovah Feehan: We need to link in the show notes to all the information for how people can learn more about Perfecting Peds and how caregivers can use your service. I think a lot of people are going to want to know. 

Brianna (Bri) Miluk: Definitely like in the show notes we'll have the link to your all's website and the podcast and your Instagram. Is there anything else we should add in there? 

Dr. Marry Vuong: I think the website has like everything on it,

Brianna (Bri) Miluk: Perfect, so- 

Dr. Marry Vuong: But I can give you like a little blurb too. 

Brianna (Bri) Miluk: Okay. Yeah. We'll, we'll add that in the show notes so that anyone listening [00:58:00] can, can make sure to connect with you all. But yeah, thank you so much. We appreciate it.

Dr. Marry Vuong: Really come to Miami if you want. 

Tovah Feehan: Girl's trip! 

Dr. Marry Vuong: I'm the queen of like free events and stuff. We have Art Basel coming up so that should be really fun. Like all the magazines have like these parties, Chance the Rapper's performing and like we have an invite for that so it's free. So come on down girls. 

Brianna (Bri) Miluk: That sounds so fun.

Tovah Feehan: Yeah. Anyone want to sponsor us to go to Miami? 

Brianna (Bri) Miluk: Yeah. We'll do another episode. We'll do it. We'll do it live.

Tovah Feehan: Oh, thank you, Marry. You're so awesome. 

Brianna (Bri) Miluk: Thank you Marry. 

Dr. Marry Vuong: Thank you. Have a great day. 

Brianna (Bri) Miluk: You too. Bye. Bye.

 
References

• NASPGHAN Guidelines https://naspghan.org/professional-resources/clinical-guidelines/
• Perfecting Peds https://www.perfectingpeds.com/
• Perfecting Peds Podcast https://www.perfectingpeds.com/podcasts/
• Perfecting Peds Instagram https://www.instagram.com/perfectingpeds/