MITES & HOW TO GET RID OF THEM

Mites, close relatives of fleas and ticks, are just as, if not more, pernicious once they have infested even one of your reptiles. The best way to get rid of them is to never get them to begin with. Unfortunately, every time you visit a pet store, reptile expo, herp society meeting, or interact with an infested herp, you risk unwittingly transporting mites into your reptile area.

Mites, like ticks, are eight-legged blood-sucking organisms. They carry and transmit diseases from one reptile to another. The mite species found infesting reptile hosts are unlikely feed on non-reptilian hosts. However, it is due to their ability to use non-reptiles as a form a public transportation that cause reptile keepers to inadvertently infect their own collections with mites.

Ticks are commonly found on wild-caught reptiles or captive bred reptiles who have been thrown in with wild-caught reptiles or kept separate but not properly quarantined. Ticks are larger than mites and, once they are locked into the reptile's skin and are feeding on blood or digesting a meal, they don't move around much. Mites are tiny and metamorphosize through several stages, some of which are non-feeding morphs. Mites are highly mobile and may be found roaming around from place to place on the reptile and in the reptile's environment. Depending on the species of mite, they may be black, bright red/orange, or the color of old, dried blood.

A wild reptile is infested with mites and ticks but, being in its native environment and subject only to the rigors and stresses of an environment into which its species has adapted over millions of years, the ticks and mites present no problem. When a snake or lizard sheds its skin, it also sheds its mites and ticks. While it may eventually become host to another couple of mites or ticks, it isn't forced, as is a captive reptile, into contact with its own shed nor with the hundreds or thousands of mites replicating all through its enclosure and neighboring enclosures...and the carpet, drapes and any other cozy spot found by roving mites.

A captive reptile is under stress from the moment it is captured or boxed up for transport. The stresses and generally unsanitary conditions found in the pet trade are, in and of themselves, unhealthful for the animals involved. Add external parasites to the mix and you have animals who are further weakened. The mites may be tiny, so small that they may be easily overlooked, but they can be dangerous. Watch for them when you are at pet stores buying your reptile or supplies for your reptiles (wood products are favorite hiding places for these pests). Watch for them when you are at the homes of other reptile keepers. Watch for them when you are at reptile expos and swapmeets (most are no better than, and often worse than, pet stores in the way the animals may have been maintained). And watch for them when you handle animals at herp society meetings or when students bring in their own reptiles to share with the class.

On lizards, reptile mites can usually be found roaming the body, tucked under the edges of scales and congregating around the eyes, ears, tympanic membrane and any place on the body where the scales are thinner. On snakes, the mites will generally be tucked under the overlapping or projecting edges of scales, around the eyes, and in the heat pits. If you can see them from about three feet away, or your hand comes away with several mites on it, then you have a severe infestation. Reptiles who are moderately to severely debilitated may require fluids and nutrient supplementation to help restore fluid balance and provide energy for rapid recovery.

Why Mites Are So Hard To Kill
The chemicals that will kill a mite will also kill the reptiles. The heat that it takes to kill a mite will also kill your reptile. Mites can be drowned, but if you are not careful, enough mites can just scurry up the reptile's and emerge from the water, hanging out around the eyes and nose (and heat pits and eye grooves of pythons and boas) until things settle down. Speaking of eyes and heat pits, mites can live their entire lives inside the tiny pits and grooves around a snake's eyes or in their heat pits, feeding and breeding and making more little mites to send off into the world. Other favorite places include the chin grooves of all snakes, in between the dorsal crests of lizards, and in the folds of soft skin around their armpits, necks and ears. While snakes can be fully submerged in water, and some lizards will voluntarily do so, lizards may have to have water poured heavily sprayed over their heads and necks to flush away the mites.

Another reason it is so hard to kill them is that they spend a lot of their non-feeding and reproduction time in tiny moist crevices, both on the reptile and in its enclosure. At any one time, you will have mites in several different life stages in your reptile's enclosure and on its body. The stages, and the time it takes to morph to the next stage at certain temperatures, are:

LIFE STAGES / MORPHS ENVIRONMENTAL TEMPERATURE   86 F / 30 C 68 F / 20 C Egg 28 hours 98 hours Larva (non-feeding) 18 hours 47 hours Protonymph (feeding) 3 days 14 days Deuteronymph (non-feeding) 13 hours 26 hours Adult (feeding, mating) 10 days 32 days

The protonymph will morph into a deuteronymph in the time indicated only if it finds a blood meal soon after it molts. If it does not, it can survive without a meal for 15-19 days before dying of starvation.

Since reptile enclosure temperatures fluctuate from their daytime gradients to their nighttime gradients, the time between morphing may be prolonged.

Snake mites are rather simple creatures. They basically travel in a line. If they hit an obstacle, like a wall, branch, water bowl, or body, they climb it rather than finding a way around it. If they are cold, they sense heat and make their way towards it. When they get too hot, they go off toward a cooler area. Moist, dark areas are preferred. If they find a hole leading out of the enclosure, they just keep walking, either walking off the edge of the table and falling to the floor, or walking up or down anything that comes into contact with the enclosure or the surface it is resting on: curtains, electrical cords, etc. With any luck (for you and your reptiles), it will starve to death before finding another host. If your cages are close together and there is lots of handling and opening and closing of doors and nice ventilation panels, the mites all too often find their way to another host, enabling them to do what they are genetically programmed to do: make more mites.

A gravid female mite leaves her host, making her way to some dark, warm, moist crevice, pit, or other imperfection somewhere in or out of the reptile's enclosure. There she lays her eggs. The soft-bodied hatchlings remain where they hatch until they are old enough to molt to the protonymph stage. So long as the crevice or wherever they are remains moist, they will not die of dehydration.

After molting to protonymph, the mite remains in its natal crevice until its exoskeleton firms up. Once it is hard and dry, the mite will no longer be in danger of dying of dehydration when it moves into drier areas. It begins to wander. If it encounters a host before it starves to death, it will lodge itself under or between scales where the skin is most accessible, and begin to feed. The mite can smell a host and will make its way towards one. The mite basically keep walking, heading towards the host-smell, warmth, and dark, stopping only when a special area on its back comes into contact with something - like the host's body.

When the protonymph has had its fill, it drops off and wanders, in its straight-line way, towards someplace dark, moist crevice. There is molts to the deuteronymph stage. The non-feeding deuteronymphs can be active but they usually remain in the crevice until ready to complete its last molt into a feeding, breeding adult.

During the latter part of the protonymph stage, or when in the deuteronymph stage, the mites pair off into sexual pairs. Soon after molting into adults, they will mate, after which they head off for a post-coital blood meal. Once they have had their fill, the gravid females head off to find a dark, moist crevice to lay their 60-80 eggs, while the males wander off to find more unmated females. After laying, females will continue to feed, her next 2-3 meals spread out about a week apart.

Effectively Killing Mites
Mites are a drag, plain and simple. They are microscopically small in most of their growth states and are not nearly as easy to deal with as a flea infestation. With fleas, you can drop the dog or cat off at the groomer's for a flea bath, and go to a movie or something while the flea bomb you set off at home is doing its thing. A couple of hours later, you are flea-free. (At least, free until you or your dog or cat brings in more fleas from outside the home.

Generally speaking, the mite treatment products available at pet stores are ineffective. There is no easy way to get rid of mites. It requires a two-pronged attack: you must aggressively treat the environment as well as the reptile. You can treat the environment with toxic pesticides after removing the reptile to a safe area. While the environment is being fumigated, you can work on the reptile using less toxic means. If your reptiles are free roaming, treating the "environment" may be an overwhelming proposition but one that must be undertaken, and undertaken aggressively, nonetheless.

Attempts to treat the environment with herbal or homeopathic remedies will not work. Many people try to avoid the use of toxic chemicals in their lives (and I am one of them), but when it comes to ridding an environment of tenacious, hard-shelled pests who, in concentrations large enough, can kill your reptile, you must act quickly and aggressively.

Another problem with eradication attempts is that many people think that simply cleaning and disinfecting the enclosure/environment will eradicate the mites. It won't. It will get rid of the loose feces and may wash away many of the exposed mites. It will disinfect the bacteria left behind where the mites were squashed or defecated. It will likely not kill the nonfeeding morphs, larvae, and laying females hidden away in deep crevices.

The following methods have proven successful in ridding an environment and reptile of mites. Note that, due to the fact that unhatched mite eggs and mites in nonfeeding states will not be affected by most of the chemicals that will kill off the adults, you will have to repeat the treatment of the environment and reptile at least once, possibly twice, within a 2-6 week period.

Treating the Reptiles
Remove the reptile from its enclosure. Snakes should be soaked in a dilute Betadine bath as described above for lizards. If the snake persists in climbing out of the tub or is too small to put in a bathtub, place it in a plastic, lidded container into which air holes have been punched, filling it 3/4 full of the Betadine/water solution. You may wish to bathe the snake in a plain water bath first to allow it to drink first, adding the Betadine after it has done so. If the snake defecates in the water, drain the tub, clean it, and draw a fresh Betadine bath.

Whether or not the snake's head was under the water, dab the eyes and heat pits with mineral oil after removing it from the bath. Check the groove under the chin as well as under all the belly scutes and in the vent folds to make sure there are no mites, dead or alive, lodged in those areas. If you find mites in these areas, you can remove them by gently rubbing them from between the scales and folds with a cotton-tipped swab dipped in mineral oil.

Treating the Environment
Remove and dispose of all the substrate in the reptile's enclosure (bag it in a plastic garbage bag and get it out of the building). Vacuum the inside of the enclosure thoroughly, especially in the angles of the walls. If the tank is made of wood or ungrouted melamine, lightly scrape the inside angles with the edge of a blunt knife, then vacuum again. You are trying to get up all the loose eggs, mites and mite feces (the white dust in the bottom of the tank).

If you have a glass or Plexiglas® tank, wipe all surfaces down with hot soapy water. Wooden enclosures may be sprayed with soapy water. Remove all soap residue. For good measure, take the time to thoroughly disinfect glass tanks by swabbing them down with a 1:30 bleach-water solution (1/2 cup bleach per gallon of water), let the solution sit for ten minutes, then thoroughly rinse out the bleach residue. Disinfecting does not kill the mites; depending on how much disinfecting solution you apply, it may drown the mites you missed during the cleaning step. Disinfection is used to kill potentially harmful organisms that may be spread around by the mites.

If you have wooden cage furnishings such as branches, caves, or rocks, bake them in the oven, set at 200-250º F (93-121º C), for 2-3 hours (depending on thickness, and longer at the lower temperature); check on them during this time to make sure they do not start to scorch or burn. Rocks may be boiled, completely submerged, for 20-30 minutes. If the wood or rock furnishings are too big to place in the oven or in a pot, soak them in a bucket, cement mixing tray, or tub, in a 1:30 solution of bleach and water (use one half cup bleach for each gallon of water) for eight hours or so, to thoroughly saturate into crevices. Rinse thoroughly, spraying fresh water into all the crevices, until they are well saturated and flushed free of any bleach residue. Let dry thoroughly, preferably in the sun, for at least 24 hours.

Wash all bowls with the bleach-water solution, rinse well and let air dry.

If you have heating pads inside the tank, unplug and remove them. Clean with soapy water, rinse off the soap, then spray them down with the bleach-water. Let them sit for at least ten minutes, then rinse clean and set aside. If you have the one of the self-adhesive reptile heating pads, check under them as best you can, or get rid of them entirely, replacing with a people-type heating pad or other free-standing heating pad or tape. Mites can crawl into the tiniest of spaces between the stuck-on pads and the glass, there to await their next metamorphosis. If it doubt, rip it off, and throw it out.

Disconnect all light fixtures and wipe them down with a damp cloth to remove any adventuresome mites and their feces.

Squeeze a "No-Pest" strip (such as the difficult to find Vapona® strip) or cat flea collar out of the inner envelope in which it was packed onto a piece of foil laid on the floor of the enclosure. Leave a bit still inside the packaging so that you can slide it back in when done. If the enclosure is a large one, you may need to set out several such strips or collars. If using a flea collar, stretch it out. You may need to cut them into pieces to prevent the from curling up again when you let go of the ends.

Close the tank and seal it up as air-tight as possible to keep the toxic pesticide fumes inside the tank where they are needed. Cover large, screened areas and ventilation panels or holes with waste paper or plastic, taping it in place. Tape over the seams and any gaps between the doors and tank. (Masking tape works well for all of this taping as it seals tightly but will come off easily and not leave a tacky residue.) Leave in place for three hours, longer for large enclosures.

When the time is up, unseal the tank, disposing of all the paper and tape into a plastic bag for immediate disposal into the trash. Push the strip or collar back into its original packaging, place it in a ziplock-type bag, then store it in a safe place. Leave the tank open and air it out for several hours. If possible, open a window in the room and turn on a fan to help air out the fumes. A space fan may even be placed inside the tank or blowing into it to speed the air circulation in it. The fumes may be undetectable to you but not to your reptile, so you want them flushed out of the reptile's environment.

Put new substrate and any new furnishings into the enclosure. Simple substrates, such as paper towels, are best used for the next couple of weeks. This will enable you to easily see if additional mites have hatched or migrated into the tank from the surrounding area. Drapes and upholstered furnishings near heavily infested reptile tanks should be checked and, if necessary, removed for thorough cleaning. Replace the water bowl, hide box, into the tank. Reinstall and turn on the heating and lighting, warm the tank back up, and place the reptile back inside.

After the reptile has been treated, it can be returned to its enclosure.

Alternative Methods and Substances

Heat
High heat may also be used to kill mites in an enclosure. Glass or other aquaria may be sealed up and placed in the sun (obviously, the animal should be housed elsewhere while this is being done!). Do this on days when the outside temperatures are in the mid-80s-90s (29-32º C) so that the temperature inside the enclosure reaches or exceeds the 131º F (55º C) for the several hours needed to kill the mites.

Ivermectin (Ivomec®)
While some vets will recommend injecting a reptile with ivermectin as a way to get rid of mites, the drug is highly toxic. Even the drug's manufacturer strongly advises against injecting it into reptiles for any reason (it is often used as a dewormer for reptiles). Another way to use this drug, however, is externally, in a spray made by mixing ivermectin and water. Ivermectin may be obtained in a vial or syringe from your veterinarian, or without a prescription in the bovine or equine section of feed stores (where it is sold as a cattle and sheep wormer under the brand name Ivomec). You will also need a 1 cc syringe and a large bore needle (which can also be obtained from feed stores or your veterinarian). Ivermectin is rather thick and the multi-dose injection bottle in which it comes is topped by a thick rubber seal. You must insert the needle through this seal to get it into the drug itself. Some smaller gauge needles can get through the seal without bending, but it will take a very long time to pull up even the small amount of the drug needed, so use a larger-bore needle if you can.

Mix 0.5cc (5mg) of injectable ivermectin (it comes 10mg/cc) per quart of water. Shake or stir vigorously and use immediately.

Follow the steps above for cleaning out the enclosure. Instead of using the pest strip or collar, soak a cloth in the ivermectin-water solution, or pour the solution into a spray bottle. Thoroughly wipe down or spray the entire inside of the tank, wiping down the unplugged heating pads and light fixtures. While the ivermectin solution is drying in the enclosure, soak a clean cloth in the solution and wipe down the reptile or spray it thoroughly with the ivermectin solution, avoiding the eyes and open mouth. Use a cotton-tipped swab to carefully apply the solution around their eyes and nostrils, taking care not to get any in their eyes. You can also use an ivermectin solution to moisten a swab or cloth and work it into r the chin grooves, under belly scutes, ventral folds, and into dorsal crests.

Put new substrate and the furnishings into the tank and replace the reptile. Monitor carefully for the reappearance of mites, repeating as necessary.

Please note that ivermectin poses a potential danger to any animal, but most especially to severely debilitated reptiles, particularly when used systemically (administered orally or by injection) on such reptiles. Take extreme care when using it topically.

Ivermectin has been reported in the veterinary and herpetocultural literature to be fatally toxic to chelonians and should never be used in or on them, nor in their environment.

No-Pest Strips
While this product has historically been recommended to be used in the tank while the reptile is in residence, an increasing number of reptile keepers and veterinarians recommend against doing so. This is due to the often fatal incidents of organophosphate poisoning from the fumes that outgas from these strips. Some reptiles may die right away, but enough may take months to sicken and die, so long from the event that the exposure to the organophosphate is not remembered and the reptile is said to have died "mysteriously" or "for no reason."

If you are planning to use the more "natural" pyrethrin products, keep in mind that this plant-derived pesticide is still highly toxic and some of the products also contain organophosphates.

NIX
One person reported using NIX (an over-the-counter preparation for human lice infestations), mixed 50/50 with water, applied to the snake. It was left on for no more than 10 minutes. The snake was then rinsed thoroughly to remove all solution residue. It was reported to have been effective. Another person reported using NIX full strength on his two snakes. He left it on for ten minutes and then put the snakes in their enclosure, into which a No-Pest strip had been placed. One snake died within 24 hours, one survived but was weak. Organophosphate poisoning from No-Pest strips can, and have repeatedly, caused damage to the reptilian (and other animals) central nervous system; many have died. It is not known in this case whether it was the full strength NIX, the No-Pest strip, or both in combination that cased the death of one and subsequent health problems in the other.

Pet Trade Mite Sprays
Many owners have tried RepRinse and Mite-Off without success. Provent-A-Mite seems to also have variable results. Any spray-on-the-reptile product is going to be worthless unless the environment is treated as well. Conversely, plain water will wash off most mites, but not the ones hiding tightly in crevices around the reptile's body. Sprays won't get to these mites, either, so you might as well use something that really is effective at less cost: plain water, with Betadine mixed in if the reptile has sustained numerous mite bites.

Dehumidifiers/Desiccants
Placing dehumidifiers in the reptile's enclosure or in the room have also been tried with varying success. Caution must be taken when keeping some reptiles in severely dry environments and the presence of toxins, including pesticides, in such dehumidifiers.

Trichlorfan
Trichlorfan, a cattle insecticide, has also been reported useful (it is apparently fatal to geckos). A 0.16% solution (8 cc of the standard 8% product mixed in 24 ounces of water) is sprayed on the reptile and left to dry thoroughly. The reptile must be kept without water for twenty-four hours so that the pesticide doesn't get into the water that the reptile may then drink. After twenty-four hours, the reptile is thoroughly rinsed off, then placed back into its enclosure with a bowl of water. The tub/shower must be thoroughly rinsed before it is used by any animal or human.

When Considering the Use of Toxins...
Working with pesticides--internal and external products alike--always involves some risk. An animal may be oversensitive to a product or to a particular component in a product. In a group of animals being treated, one may suffer while the others remain unaffected. This could be due to an extreme sensitivity or an unknown underlying physiological condition.

Many people have for years used pest strips inside their reptile enclosures with no apparent ill effect. It is best, however, to never leave a pest strip in an enclosure with an animal, nor even open in the same room with an animal. Reptiles metabolize substances at different rates than do mammals and birds. Do not assume that what is safe for one animal (such as a flea collar for dogs or cats) is safe for your reptile.

A Note on Treating with Apparently Innocuous Substances
Use of an oil, such as olive oil, mineral oil, or baby oil, to completely coat the reptiles is often recommended. However, a severely debilitated animal may suffer. Indeed, some owners have reported their reptiles dying after being liberally coated with oil.

Other seemingly innocuous substances, such as Listerine® mouthwash, may also be harmful if used inappropriately. In a very dilute form (such as 1 pint of Listerine to a standard sized bathtub filled 1/3-1/2 with 80-84 F water), Listerine acts as a mild antiseptic on the mite bites, similar to the effects of the Betadine. One ball python owner in England reported to the maker of Listerine that his snake died after being bathed in a bath to which Listerine was added. The unknown factors which may have caused or contributed to this outcome, however, are still unknown: the snake's state of health to begin with; how much Listerine was added; how hot or cold the water was (was the snake blanched by hot water or did it suffer rapid hypothermia from cold water immersion?); the residual effects of the toxic substances used in the enclosure, or used previously on, or injected into, the snake itself; etc. Without some idea of the snake's state of health before it was put into the bath, how it was treated subsequently, and the actual conditions of the bath, it is impossible to know for sure whether the Listerine (or, as in the above paragraph, the olive or other oils) were the actual cause of death. It is more likely that something else was going on or the owner did not properly dilute the mouthwash.

Betadine is a topical antiseptic safe for use on snakes and lizards. When properly diluted, it is safe to use for bathing snakes and soakable lizards. Used improperly (for example, forcing a reptile to submerge fully in full strength Betadine or other iodine product), or using the Betadine Scrub instead of the Betadine (Betadine antiseptic has only a fraction of the amount iodine in the Scrub), or when other factors come into play that have nothing to do with the safety of the Betadine, including hypersensitivity to iodine, the reptile may die.

For that matter, plain water may kill a reptile if the water is too deep, too cold, too hot, the animal too weak, or too panicked to find the surface of the water to break through to breathe.

Finally, while the saying "if some is good, more is better" may be a perfectly fine dictum when applied to something like chocolate, it could cause problems with it comes to using any substance, toxic or non-toxic, in a manner not specifically tested for or approved of by the manufacturer. More is not necessarily better, and less is often smarter.

Self-treating animals always carries the potential for harm, even death. If you have any questions about these or other procedures or products, they should be discussed with an experienced reptile veterinarian.

A Note on the use of Organophosphates
Despite growing recommendations against putting pieces of pest strips and flea collars inside the reptile enclosures when the reptile is in there, herp keepers continue to recommend this method. The reason may be that the conditions, including death, that result from such exposures may be subtle enough, or remote enough from the proximity event itself, that reptile keepers whose reptiles have been poisoned through the chemical exposure do not associate the outcome with the event itself.

Sue Barnard, Lead Keeper in ZooAtlanta's Department of Herpetology, writes in her book, Reptile Keeper's Handbook (Krieger Publishing, Malabar FL. 1996), discusses using this to treat a room, rather than an individual enclosure, with the reptile itself relieve of its load of mites by soaking in water.

"[Mites] may migrate up to 15 ft a day (Lawrence, 1983), therefore it is best to treat the entire area (room) with dichlorvos-impregnated pest strips. To provide immediate relief to a mite infested reptile, soak the animal in tepid water to drown as many mites as possible. Those mites which climb to the animal's head can be wiped off with a moistened piece of gauze. Soaking reptiles in water, however, does not eliminate mites altogether ."

Reptile and exotics veterinarian Douglas L. Mader, goes into greater detail on the dangers of pest-strips and other products containing organophosphates in his chapter, Ascariasis, in his book, Reptile Medicine & Surgery (ed. D. L. Mader, W.B. Saunders Company, Philadelphia PA. pp. 341-346):

"There are a number of other mite treatments that have been reported in both the veterinary and herpetological literature. The more common include placing cut pieces of either a dog or cat flea color or insect pest strips inside or on top of the affected reptile's cage. The pieces are left in place for varying lengths of time (depending on where you read the information).

"The active ingredient in these collars and strips is dichlorvos (DDVP, Vapona), an organophosphate. Organophosphates are cholinesterase inhibitors and have the potential for being very toxic. In some cases the presence of these strips can cause the reptile to develop a rapid, progressive paralsysis. However, what commonly occurs is a chronic, insidious deterioration of the animal from the prolonged contact with the poison. This may take months, resulting in the reptile dying and showing no outward signs [thus rarely are such deaths associated, by the owner, with the use of the dichlorvos product]. Even on necropsy there are no obvious lesions related to the organophosphate.

"Although many herpetologists swear by this treatment method, the author has seen far too many deaths resulting from pest strips, and their use is strongly discouraged.

"There is another important medical note regarding pest strips that should be mentioned. Many of these pesticides have been proven to be teratogenic in mammals. A teratogen is anything that causes birth defects. Also, there may be other negetive effects on reproduction and fertility that have not been studied. To the author's knowledge, there have been no studies performed to determine if there are any negative effects on reproduction and fertility in reptiles.

"DDT (a chlorinated hydrocarbon) and diazinon 25 E have appeared in past literature as additional treatments. It is now felt that both are too toxic and should not be used now that safer methods are available."

Other signs of organophosphate toxicity include excessive salivation, ataxia (inability to right oneself) and muscle tremors. It should be noted that many of the pyrethrin products, touted as being "natural" due to their being drived from chrysanthemums, also contain organophosphates. "Natural" pesticide products can not be assumed to be safer or healthier than man-made chemicals just because they are derived from plants.

References

• Barnard, Sue. 1996. Reptile Keeper's Handbook. Krieger Publishing, Malabar FL.
• Camin, Joseph H. Observations on the Life History and Sensory Behavior of the Snake Mite, Chicago Academy of Sciences, Special Publications No. 10. Reprinted from Georgia Herpnotes 13(2):6).
• Klingenberg, Roger J. 1993. Understanding reptile parasites. Advanced Vivarium Systems, Lakeside CA.
• Mader, Douglas L. (ed.) 1996. Reptile Medicine and Surgery. Krieger Publishing, Malabar FL

Caresheet by Melissa Kaplan.