Fun With Food Program

Jack eats.jpgJack went through an intensive feeding program at Seattle Children’s Hospital at the age of two-and-a-half to transition him off of his G-tube and to oral feeding. The program was run by Karen Quinn-Shea, an occupational therapist at Children’s Hospital in Seattle. We dubbed the program “Fun with Food” to help two year old Jack understand what we were doing.

The intensive feeding program at Seattle Children’s Hospital is two weeks long and conducted at the facility. Each day during the first week (Monday – Friday), Jack and I would have breakfast, morning snack and lunch at the hospital with the therapist. He was still napping so we would come home after lunch and I would work at home on afternoon snack and dinner. Older kids stay through afternoon snack. In between each meal/session we would play at the hospital or go to a nearby mall to have a break. Below is a schedule I sent out to friends and family to illustrate our day.

7:00 am – leave house
7:45 am – arrive at Children’s Hospital and say hello to all of the fish
8:00 – get weighed and head to the cafeteria to pick out our breakfast
8:15 – sit down to breakfast
8:45 – breakfast finished, time for tube feeding and head out
9:00 – get to UVillage Starbucks for a latte
9:20 – play on the UVillage play structure
10:10 – head back to Children’s
10:30 – meet Karen for snack time
10:50 – snack finished, time for tube feeding
11:10 – check in at Children’s playroom
12:20 – meet Daddy at waiting area
12:30 – go to cafeteria to pick out lunch
12:40 – sit down for lunch
1:10 – lunch finished, time for tube feeding
1:30 – leave Children’s for the day
1:38 – Jack asleep
2:15 – arrive at home, transfer Jack and unpack car
3:00 – Mommy finally sits down
4:00 – get Jack up from nap
4:15 – have snack
4:35 – snack finished, send Jack outside to play
5:30 – Daddy home
6:30 – sit down for dinner
7:00 – dinner finished, time for tube feeding
7:10 – Jack and Daddy play
7:40 – bath time
8:00 – bedtime stories
8:10 – Jack nigh-night
8:15 – Mommy and Daddy collapse on sofa

As part of the program, we cut Jack’s tube formula feedings back from 35oz to 18oz at the beginning of the program. Throughout the program we cut back his formula to only one nighttime formula feeding and the rest water. We used the G-tube to help with his fluid intake and keep him hydrated until he was able drink enough on his own.

The middle weekend of the program gave us our first taste of what life would be like after the program when we were on our own. During the second week of the program we started with the same schedule and gradually tapered down to just having lunch at Children’s on the last Friday. After that we would have weekly weight checks at our pediatrician’s office and communicated with the team via email.

During the early meals/sessions, Jack would be rewarded for taking bites of food with a small toy being activated (like a windup toy) or a movie turning on. In order to keep the toy going or movie on he would have to continue to take bites. Since he was old enough to understand cause and effect he quickly figured out that he could get rewarded for taking bites. By the end of the program he didn’t need the stimulus as much and would just sit and eat with us. This is also when and how Jack learned to do cheers with a cup. What better way to incent someone to drink, right?

At the beginning of the program Jack ate only 12% of his calories by mouth. By the end of the program he was taking 71% of his calories by mouth. He came through the program very well, preferring to try a variety of different foods initially before increasing the volume of particular foods.

The timing of the program was perfect for Jack, because he wasn’t fully aware of what his G-tube was for. We sat him at the table with us for each meal and would give him finger foods and a cup to practice his eating skills. At two and a half he was willing to follow our directions and understand the concept of cause and effect.

Over the next three months we gradually tapered off all his G-tube supplements, formula first then water. Six months after that when Jack was just over three years old we removed his G-tube for good. And he symbolically and uneventfully threw it in the garbage and never looked back.

We are forever thankful for this program and the staff at Seattle Children’s that worked with us through it. Jack’s transition to eating couldn’t have been any smoother.

Blendarized Food

Jack tube feeding When Jack was about 15 months old we decided to start him on a blendarized food regime. He was tube fed during this time, so he was only getting formula.

We knew that in the future we were going to work with him to eat orally and wanted to make sure that his stomach was used to digesting food. Some of our doctors had mentioned this was a good way to accomplish this.

At Children’s Hospital I was connected with a dietician who specialized in creating blendarized diets. We worked together to create a recipe that had a balance of nutrients, fats, protein and carbs. I purchased a Vitamix blender that would be able to grind up the ingredients enough to easily pass through his feeding tube. I did find that some proteins were difficult to get fine enough. Since making these foods were a bit time consuming I would give him up to two feedings a day. The other feedings he would continue to have age-appropriate formula.

Using these recipes we were also able to test his GI system and see if he had grown out of this milk protein intolerance. It was a simple way to introduce a small amount of dairy and see how he did.

A year later when Jack went through the feeding program and started eating he didn’t have any GI upset. I believe that some of this was due to his body learning to digest other foods with the blendarized diet.

Swallow Study

feedingOne of the common tests that doctors will run for children who aren’t feeding well is a swallow study. A swallow study will show if fluid is going into the lungs (aspirating) while feeding and if the swallow mechanism is working correctly.

A swallow study is a relatively simple procedure, but can be very helpful if you suspect that your child might be aspirating when feeding. Aspiration is very dangerous and can lead to a variety of health issues.

A speech-language pathologist performs the swallow study. For infants that are breast or bottle feeding, barium is added to bottles of formula in a variety of thicknesses. Usually they have one without thickener and one or two thickened bottles. Will sat in a seat similar to a car seat and I fed him the bottles as the technician operated the videofluoroscope which is similar to an x-ray. This machine is able to record video instead of just one image like a standard x-ray. This allows the specialist to view what is going on inside the baby’s mouth and throat as they swallow.

As the baby swallows the different bottles with a variety of thin or thickened liquid, the specialist can watch the path it takes from the mouth down the esophagus and into the upper stomach. They will see if the child is able to successfully block their airway or if they allow any of the fluid to leak through. If the child is allowing thin fluid into their airway and ultimately their lungs, the doctors will test to see if the child is more successful with thickened formula. In severe cases where children aspirate all fluid alternative feeding methods will need to be used.

When Will was a baby he had a small swallow issue, which affected his bottle feeding. He was letting fluid into his windpipe, but luckily his vocal cords were clamping down and pushing the liquid back out. Thickening his formula allowed his swallow mechanism to work correctly and keep the liquid out of his windpipe. Jack also had a swallow study done, but he didn’t show any signs of aspiration.

Thickening formula can be achieved very simply with a few methods.

· Rice cereal – We found that it clogged the bottle nipples and led to more issues.

· Powder thickeners – We found that these didn’t clog the bottle nipples like the cereal. However they would continue to thicken the formula throughout the feeding, which can prove problematic.

· Gel thickeners – We had the most success with gel thickeners. They didn’t continue to thicken over time, so we could maintain the correct consistency.

Once we started thickening Will’s formula he went back to eating normally. The swallow study was one of the easiest procedures required of us with little to be concerned about.

 

Resources:

http://www.asha.org/public/speech/swallowing/Videofluoroscopic-Swallowing-Study/

http://www.refluxrebels.com/Acid_reflux/Acid_reflux_formula_thickening.html

Hard, But Good Decisions

Every parent is faced with difficult decisions around our children. In the moment it can feel overwhelming, but looking back you realize although it was hard it ended up being a sound decision.

In Jack’s first year of life we were faced with two such decisions. Although they were almost eight years ago I can remember them like they were yesterday.

Jack NG tubeThe first decision was putting in his feeding tube. We had struggled with bottle feeding him for four months, working with therapists and trying everything from different bottles to different formula and feeding techniques. For him, eating hurt so much that he would take a little bit and then stop. At four and half months old he was still only eating the same amount as he did as a newborn. After many conversations with our pediatrician we decided to put in the NG tube.

We were worried that not only was he falling off of his growth curve, but he may not be getting enough fluid to stay hydrated. She explained the process and that this would buy us some time, taking pressure off of us trying to feed him and him trying to eat. Even though the thought of sticking a tube up your child’s nose (yes, I had to do this) was horrifying, we knew it was the right decision.

After the tube went in, Jack’s personality blossomed. The pressure was off of him and he didn’t hurt anymore. We were able to enjoy him and not worry constantly about how much he was eating.

Eight months later we were faced with another difficult decision, moving from an NG tube to a surgically implanted G-tube. This forced us to realize that he was going to be tube fed for years, not months. We had tried many times over those eight months to get him to eat on his own, but the memories of the pain were still so great that he would try briefly only to stop again.

PEG tube.jpgThe NG tube also had become a hindrance for him. He was crawling and starting to play with other children. The tube was a point of interest on his face and children would grab at it. He was also vomiting several times a day due to the tube in his throat. We also were tired of the stares that we would get from people when out in public.

The night before his surgery I took a photo of his clear tummy, knowing that it would never be the same. He would either have a tube sticking out of his stomach or a scar where the tube was. We knew it was the right decision, but it is always hard to admit your child into surgery.

After the surgery, we got his amazing cheeks back (no more NG tube taped to his face) and his personality continued to bloom. In doing so, we bought ourselves more time to kick-start his eating while doing it on his and our terms. Jack has been eating on his own for years and after removing the G-tube, never looked back.

Looking back these were extremely hard times, but we know we made the correct decisions for our family and our child.

When have you been faced with a difficult decision?

Milk Protein Intolerance in Children

feeding WillBoth Jack and Will had milk protein intolerance from birth until they were about 18 months old. We were lucky it wasn’t an allergy as children are less likely to grow out of one.

Milk protein intolerance is the body’s inability to correctly process proteins. These proteins then pass into the intestines where they can cause gastrointestinal distress including pain, bloating, constipation, diarrhea and blood or mucous in the stool. Milk protein intolerance can range from being minor and easily addressed by avoiding dairy, to severe where all products containing any complex proteins must be avoided. My boys had the latter.

Milk protein intolerance is different from lactose intolerance. Lactose intolerance is the inability to process the milk sugar, lactose, because a person’s body doesn’t produce lactase.

For mothers who are breastfeeding, eliminating dairy products can successfully alleviate a baby’ symptoms if its intolerance isn’t severe since the proteins the mother consumes pass through intact to her milk. In our case even the most minor amount of milk proteins in my diet — ones I didn’t even know were there – caused the boys to scream and cry after feedings.

There are some over the counter formulas that are touted as being hypoallergenic and given to babies who show signs of GI distress, including crying after feedings and blood or mucous in their stools. While these formulas do have partially broken down proteins, they do still contain larger proteins that can affect babies with severe intolerance, like my kids. Luckily there are formulas available (only by prescription) that are broken down to amino acids and short peptides that make the formula easily digestible.

We didn’t realize how severe Jack’s milk protein intolerance was until after he had his feeding tube inserted and we started giving him the amount of formula he was supposed to be getting (prior to the tube, he was not getting enough due to his food refusal). He would wake up screaming in the middle of the night obviously in severe pain. Once we put him on the special formula he had no more problems. With Will, once he showed signs of GI distress three days after birth, we put him on the special formula right away.

We did have Jack allergy tested at six months of age to make sure that it was an intolerance and not an allergy. Both boys were able to tolerate dairy by age 18 months and have consumed milk products ever since with no issues.

Understanding Feeding Tubes

NG-tube.jpgOur oldest son Jack had a feeding tube for three years from age four months to just past his third birthday (the last six months we didn’t use it, but needed to keep it just in case there was a set-back). Since he suffered from a feeding aversion due to severe reflux and milk protein intolerance, it was a difficult “choice” we had to make. While the “choice” was an obvious one for us, other children with certain medical conditions require feeding tubes as they are unable to eat orally.

Although Jack could drink a bottle when he was an infant it caused him so much pain that he refused to do so after several months of associating pain with eating. After fighting with him to eat (feedings would take over an hour at times) we decided it was in his best interest and ours to insert an NG feeding tube to provide a painless feeding process and an opportunity to reboot his pain memory. It was the best decision we ever made. He immediately changed into a happy baby and we got to relax and be somewhat “normal” parents.

NG-tube or Nasogastric Tube
An NG-tube is a small tube that is inserted in the nose and runs down the esophagus into the upper part of the stomach. It can be used for continuous feedings or bolus feedings where large amounts are given over a short period of time similar to giving a bottle. Once taught how to place the tubes, parents are able to replace them as needed. Typically NG-tubes are used for children that will be tube fed for short periods of time, like a few weeks or months. They can be removed easily and although not painful to replace, can be uncomfortable and very unpleasant for the parents placing it.

PEG tube.jpgSeven months later we had a G-tube surgically implanted into his stomach, because we concluded with his doctor that he was not eating enough orally and the NG tube had outlived its life. Jack started with a PEG tube for three months and then had an endoscopy to change it to a MIC-KEY button. After that we changed his MIC-KEY button every three months at home.

G-Tube

A G-tube is inserted directly into the stomach through a hole made in the abdominal wall. The hole is made surgically. Like the NG-tube, feedings can either be bolus or continuous. There are two main types of G-tubes, PEG tubes and buttons.

PEG tube – The tube has a small mushroom shaped end that holds it in place and has about 5-6 inches of tubing on the outside that connects to the feeding machine. This tube can only be changed or removed surgically during an endoscopy. Usually this is the tube that children start with when a G-tube is placed. After the stomach and abdomen fistula have healed after surgery (approximately three months), the PEG can be replaced with a lower profile button.

MIC-KEY button.jpgButton – The two types of buttons are MIC-KEY and BARD. The MIC-KEY has a small balloon that is inflated with water after it is inserted into the fistula to hold it in place. The external part of the button is flat against the stomach. After being properly trained parents are able to change MIC-KEY buttons at home.
The BARD button has a small dome shaped plastic piece that holds it in place. It can be inserted without surgery, but can be more uncomfortable and should only be changed by a nurse or doctor.

Converting to the G-tube moved the NG-tube off of Jack’s face and to a more inconspicuous location, eliminating the risk of accidental removal by a stray hand. This also eliminated the stares while out and about in public. We learned to cope with the latter but it was always very hard dealing with educated adults who were staring at our beautiful son. Putting your child through surgery is never easy, but we felt it was the right choice for us and Jack is living proof that it was.

g-tube fistula.jpgOnce Jack learned to eat orally through a wonderful food re-introduction program at Children’s Hospital, and after six months passed without using it, we removed the G-tube. He had a small indentation on his stomach until last summer when he requested that we have it sewn up.

Below are descriptions of other types of feeding tubes that are also available. Jack had an NG-tube, a PEG for three months as his first G-tube, then a MIC-KEY button for the remainder of his time.

NJ-tube or Nasojejunal tube
Similar to the NG tube this one is inserted in the nose, going down the esophagus, but it continues through the stomach into the upper part of the small intestine called the jejunum. This tube is used for children who can’t handle having feedings in their stomachs. Since the jejunum can’t handle large amounts of food at one time these feedings need to be continuous.

GJ-tube or Gastrostomy-Jejunostomy tube
This tube is similar to the G-tube in that it enters the stomach through the abdomen wall, but it has a longer tube that is guided into the jejunum. This is used for children who need to have the port in their stomach, but can’t handle food in their stomach.

J-tube or Jejunostomy
This tube is placed directly into the jejunum through the abdominal wall. These are used for children who need to have food placed directly into their intestines and can handle having the tube directly in the intestine.

 

    

I sourced my information from the following sites
http://www.parent-2-parent.com/tubefeeding/type.htm
http://huntingtondisease.tripod.com/feedingtubes/id1.html
http://www.rileypediatricsurgery.com/Gastrostomy.htm

Coming Full Circle

On Tuesday Jackson had surgery to remove what is left of his G-tube hole. This is something he has been asking about for the last year. It was always his choice, but we and his doctor wanted him to be a bit older, which is why we are doing it now.

The procedure involves cutting out the skin cells that have grown down into the original hole when it healed almost six years ago. When we removed his G-tube three years ago (which only involved removing the tube and covering it with a band-aid) the hole closed up internally, but left a small hole/divot on the outside of the skin. So now he will have a little line scar instead of the divot that was there previously.

Returning to Seattle Children’s Hospital for things like this takes me back to the first 15 months of his life, with four overnight stays, ten procedures and to many appointments to count. But now this phase is complete.

Although this procedure is cosmetic and not required, I knew he would want to do it someday. Last night as I scrubbed him down with the antimicrobial soap I was looking at his tummy, thinking about how it would look different today. We actually took a picture just so we could remember. I remember the night before his G-tube surgery and looking at his tummy thinking how it would never be perfect again. But the tradeoff at the time was we got his cheeks back so it would be worth it (the NG tube was snaked up his nose and into his tummy and the end had to be taped to his cheek).

  NG tube PEG tube

  MIC KEY button tube hole

It is never easy to have your child go under anesthesia and I can’t say if it is easier when they are younger and not aware or older but can tell you if they are in pain. He was very nervous, but all the doctors, nurses and staff at Seattle Children’s are amazing and handled his fear and questions very well. Jim went back with him when they put him to sleep and held the mask. I did it once for his first procedure when he was six months old and realized that I just can’t handle watching them put my child out. As a mom I can handle a lot of things (inserting NG tubes and G-tubes, giving enemas, fixing wounds), but that is too much for me. Although it clearly affects Jim, luckily he can do it and Jack was very brave.

Dr. Goldin, who was actually the one who helped put in his G-tube, removed the fistula (skin cells in the tube hole) and sewed up the stomach wall, fascia (a layer of tissue on the abdominal wall) and the skin. Jack can’t swim for a week, but other than he do most anything once he feels up to it.

So our circle with feeding tubes is complete. We have gone from an NG tube to a PEG tube to a MIC KEY button to an eating boy to a MIC KEY removal and finally no more tummy hole. Now I just need to finish the book about our journey so others can learn from our experience and hopefully benefit.

The illusion of normal is gone

The last few weeks have been very hard. My last few posts have been light and fun, but this one isn’t. I have been struggling with writing this for a couple of weeks, going back and forth about what to say and not say, but I have decided to put it out there. After all this blog is about the good and the hard.

We are struggling. Will is not taking to eating solid foods. He was doing OK for a while, but has gone backward since we returned from our ski trip. He ate great while we were gone, but as soon as we got home he went back to putting food in his mouth chewing it and spitting it out. For about a week the only things he would swallow were cheerios.

Then he started swallowing more for a few days, then started refusing to put things in his mouth all together. It has been getting worse and worse, until last night at dinner and today at lunch where he took about 3 bites. Then he sits in his chair and hums. It is the most grating irritating sound you can imagine and he will do it for minutes on end. No matter what you give him it doesn’t stop.

So I have lost it at least a couple of times (including today at lunch) calling Jim crying if he happens to be at work or just putting Will on the floor and going to a different room. As a mom you aren’t supposed to admit that you loose it, but we all do. I try so hard to keep it together, but when I do loose it I realize that part of what I am feeling is my frustration with my kids not be “normal.”

I have to let go of the idea that my kids will be “normal.” But there is something so comforting when you go to the doctor and they say yep, they are normal or this is a normal step. When it comes to food and eating we have never been normal. At least with Jack it happened early on and was very obvious that he was going to follow his own path.

Will has bounced in and out of normal since he was born and I think that may have been harder. He was breastfeeding great, then the milk protein intolerance showed up. Then reflux and we got both of those under control. Then his refusal in August and we figured out it was his swallow and got figured out. Then he didn’t want to purees off the spoon, we thought he want to pick things up. So I worked with him and found foods that would work. Now he doesn’t want any of it.

The thing that looms for me is that we are supposed to be transitioning him from the bottle as his primary food to solid food right now, in hopes that he is off the bottle by 14 months. There is no way that is going to happen.

I just don’t understand why. Why do my kids have these issues when so many around us don’t have any. We were supposed to have been dealt our hard cards with Jack, but then we found out about Will’s eyes. I had almost come to terms with eyes, but when we have more struggles I feel overwhelmed. I know there are families that have a lot bigger issues and I don’t want to take anything away from them. I don’t know how they handle it so well.

So my illusion of normal is gone. I had thought maybe we would get back there, but I know better now.

Fingers are for feeding

This week we had our appointment with Robin Glass, Will’s feeding specialist. We haven’t seen her since early October, so I was interested to get her perspective on how Will was doing with his solids. He is very interested in food, just not really into using the spoon. He will pick up anything that I put on his tray and taste it. Some stays in and some comes out, but he is very enthusiastic about it. With the spoon, he will open his mouth a few times, but not really close around it to remove the food. He does much better when I put food on my finger and put it in his mouth.

Robin confirmed that it is not uncommon (double negative, sorry) for some babies to decide that finger foods are more to their liking and loose the spoon early. Will does much better with foods that are thicker, (not the thin baby food purees) keeping the food in his mouth and moving it around to chew it. We actually tried turning the spoon over and putting it in his mouth and using the handle, which he did much better. I guess he just has to do it his way.

Overall, she was very happy with his progress. We still need to work on his chewing technique and his pincher pick-up, but those will come. He is so enthusiastic and willing to try most anything, his skills just don’t match his will yet. I am going to give him fork-mashed or lightly ground foods, instead of purees and soft finger foods to pick up. Everything will be easy for him to “chew” and get to the size he can swallow.

It is fun to watch him eat. He is a full contact eater, enjoying food every possible way, in his mouth, up his nose, in his hair and ears. He will even work to recycle some off his bib if he runs out of stuff on his tray. I am going to try to find some things for Thanksgiving that he can have, maybe some mashed potatoes without dairy and some pumpkin (without the pie).

At the end Robin said that we don’t need to come back to see her unless we have a question. Great! She is such a wonderful person, it will be sad not to see her, but exciting to get good news from doctors over there.

P.S. I have a freezer full of organic baby food purees, if anyone wants them, please let me know.

Acknowledging the fear

Yesterday I met with Robin Glass our feeding therapist to work with Will on solid feeding. (Side note – he is taking a bit longer to get the hang of it, so we are seeing her for pointers. More in that in another post.) After Will finished his solids session, she sat and watched me feed him his bottle and we chatted. This week has been a difficult one for us, because Will has been cranky, uncomfortable and not wanting to eat very well; Monday being the hardest day.

As I told her about the week she said “it is good that you aren’t letting the fear run away with you. You are acknowledging that you have the fear, which is good, but managing it within the current situation.” I responded by saying that I was trying to do that, because for us the fear of what happened with Jack’s eating is always there. There isn’t anyway it can’t be with all we went through to get him where he is today. I work really hard not to overreact to subtle ups and downs with Will’s eating, since that is normal baby stuff (normal baby stuff?!, we actually get something “normal” for a change.)

I told her that everything that went on 6 weeks ago, his eating dipping down and then recovering after we made some changes to his routine (thickening his formula and more on demand feeding) has helped me realize that he is a different child and I can start to put the fear in the back of my mind. It all came racing forward in early August, but we figured it out and him out and got the ship righted again. Jack never recovered, for him once the downhill slide started it never came back.

The last thing she said to me was Will doesn’t refuse food, he just lets us know when he is done. Will is engaged in the bottle and feeding until he gets full/done and then lets us know. Jack wouldn’t engage, he would eat just enough to get rid of whatever hunger pain he had and then scream to stop. For him he never relaxed into the process which Will does do.

It is so helpful to have her around, even if our visits are more for me than Will. In some way Will’s doctors have become our therapists as well (especially our pediatrician.) I don’t know where we would be without them. Thank you Robin for letting me know it is OK to acknowledge the fear so it will not run away with me.

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117-202

70-697   , 200-310   , c2010-657   , 70-487   , 3002   , C_TSCM52_66   , 70-461   , 70-463   , API-571   , 642-997   , HP0-S41   , EX200   , 1Z0-470   , C_TERP10_66   , CCA-500   , 300-085   , MB5-705   , 400-201   , 000-106   , 300-115   , MB6-703   , 101-400   , 070-466   , 300-206   , 70-412   , HP0-S42   , 98-365   , 9L0-012   , 70-533   , CAP   , 70-347   , 350-018   , API-580   , 70-178   , M70-101   , 70-466   , 70-462   , CAS-002   , 9A0-385   , 642-999   , LX0-103   , 070-462   , AX0-100   , 1Z0-061   , 2V0-621D   , SY0-401   , 70-534   , PEGACPBA71V1   , PR000041   , 220-901   , C_HANATEC_10   , LX0-104   , 220-801   , PEGACSA71V1   , 000-089   , JK0-022   , M2090-732   , 1Z0-803   , 70-413   , 400-101   , 1Z0-144   , 70-346   , MB6-702   , 070-410   , AND-401   , 1Z0-809   , 300-070   , AWS-SYSOPS   , 400-051   , VCP550D   , 210-065   , NSE7   , C_TFIN52_66   , CGEIT   , CRISC   , 070-487   , NS0-157   , 70-417   , NS0-506   , 599-01   , CQA   , 600-455   , 1z0-434   , ICBB   , ICGB   , C_HANAIMP151   , MB2-704   , JN0-633   , 350-060   , 70-270   , IIA-CIA-PART3   , 1V0-601   , C_TAW12_731   , E05-001   , 200-120   , JN0-102   , 070-483   , 300-208   , 210-060   , ADM-201   , 1Z0-067   , 810-403   , 300-101   , 640-911   , C_TADM51_731   , 642-732   , 1Z0-804   , 300-209   , 70-480   , N10-006   , 74-343   , 600-460   , 350-029   , 70-980   , PMI-001   , C_HANATEC151   , 117-202   , 350-050   , VCP550   , 1Y0-201   , 000-017   , CBAP   , C2010-595   , 70-486   , 1Z0-051   , 700-501   , 1Z0-062   , c2010-652   , PK0-003   , OG0-093   , 000-080   , 1Z0-808   , 1V0-603   , 2V0-620   , 1Z0-434   , 700-037   , 101   , 500-260   , 220-802   , MB2-708   , 156-215-77   , CISSP   , IIA-CIA-PART2   , MB2-707   , 300-320   , 70-332   , 000-105   , 70-243   , 9L0-066   , 70-410   , 1K0-001   , 700-260   , 70-177   , SSCP   , 74-678   , 070-461   , CISM   , 70-411   , CISA   , 640-916   , 210-260   , 712-50   , M2090-744   , 350-080   , 1Z0-068   , 70-483   , 70-246   , JN0-360   , PMI-RMP   , 70-680   , 70-494   , 640-875   , 350-030   , 70-488   , JN0-332   , 102-400   , 352-001   , PMI-100   , EX300   , IIA-CIA-PART1   , 100-101   , NSE4   , PMP   , 1z0-808   , 070-346   , 350-001   , ITILFND   , 300-075   , 2V0-621   , OG0-091   , 640-692   , 1Z0-060   , 70-981   , 300-135   , CQE   , 70-532   , JN0-343   , 000-104   , 70-697   , 200-120   , 70-347   , 156-215-77   , C_TAW12_731   , M2090-732   , 70-243   , c2010-657   , 70-463   , 1Z0-434   , NSE7   , 70-347   , 70-462   , 70-417   , 300-209   , API-580   , 70-243   , 70-463   , NS0-157   , JN0-633   , 210-060   , 70-981   , 070-410   , 70-410   , c2010-657   , C2010-595   , 74-678   , ICGB   , N10-006   , ITILFND   , 220-901   , 70-533   , 700-037   , 1Z0-803   , 300-115   , VCP550D   , 70-483   , 810-403   , 700-037   , CGEIT   , 000-106   , 1Z0-434   , 500-260   , 1Z0-808   , 70-494   , 400-101   , M2090-732   , CQE   , MB2-708   , CAP   , 350-018   , 70-243   , 70-462   , CRISC   , 300-206   , C_HANATEC151   , 642-997   , C_TSCM52_66   , 1Z0-060   , 74-678   , 1Z0-808   , NSE7   , 300-070   , JK0-022   , 70-461   , 2V0-621   , 100-101   , JN0-343   , 70-486   , 70-533   , 600-455   , MB6-703   , 642-732   , 642-997   , 352-001   , PMP   ,