I’ve written before about how children from poor families have a higher chance of needing PICU care than do children from more affluent families. Eligibility for Medicaid is a good marker for this; nearly half the population of most urban PICUs is made up of children on Medicaid, even though the national average (it varies a little from state to state) for children on Medicaid is about 25%. So poor kids are more likely to become critically ill.
A report from the Robert Wood Johnson foundation, a renowned health policy organization, lays out how poverty correlates so closely to poor health. This chart is the most telling. It measures a somewhat vague quantity, something they call “children in less than very good health.” They obtain this value by surveying parents, so you could quibble about the validity of whatever it is the term measures. That quibble would make sense to me if the numbers weren’t so striking.
But they are striking. For example, among white, non-Hispanic children, 20% of poor children have “less than very good health,” compared with 6% of well-off children. The differences among black and Hispanic children are much more dramatic. Nearly 50% of poor, Hispanic children are not in optimal health.
What this means to me is fairly obvious, and it has been obvious for a long time — health status is linked to socio-economic status. We shouldn’t need a study to tell us that, but it is helpful to have such a graphic demonstration of the effect. I’m sure it’s partly because poor families can’t afford health insurance. But that isn’t the whole story — all of these poorest children, the group with the most severe health problems, would qualify for Medicaid, even in the states with the most stringent requirements.
Thus whatever we do about healthcare reform will be closely linked to what is happening in the economy. Perhaps the best thing we can do for healthcare is reduce poverty.
Here is another post about using medical evidence. My last one dealt with the usefulness (or not) of expert opinion as a basis for evaluating the validity of a medical claim. This post discusses the next highest item on the hierarchy of medical evidence — the case report.
The simple case description is the oldest tradition in medical research, dating back hundreds of years, long before biostatistics had even been thought of. The medical journals of the nineteenth and early twentieth centuries are filled with doctors’ descriptions of individual patients with particular diseases — how the problem began, how it evolved in the patient, and what happened to the patient. The writer usually then speculated about what the particular case taught us about the malady. He would usually compare his findings to whatever previous authors had written about the disease.
We still use this technique today, although such case reports are very weak tools for deciding anything important about diseases. Any nonphysician can see the pitfalls in this sort of medical evidence. It is totally dependent upon what happens to turn up in the doctor’s individual practice, and there is no way to tell if a particular case is representative of all, or even most, instances of the disorder. It is merely an anecdote of one occurrence.
Slightly better than a case report is a collection of case reports, or case series. There is also a very long tradition of these in medical writing, and a very large series does tell us things that are increasingly likely to be true as the series gets larger. But there remains a huge problem in using case series to understand whatever the problem is: they are not a random sample of all cases; rather, they were selected in ways that easily introduce bias. For example, a particular doctor may become known as an expert in a particular disease and so people with the problem come to see him. Or perhaps only patients with more severe, unusual forms find their way to him because the milder varieties are cared for by someone else or are never seen by a doctor at all.
One can imagine a large number of other circumstances that would introduce bias into whatever the doctor writing the case series would see. These issues make case reports and case series only slightly better than expert opinion as a tool for understanding medical causation and treatment. These pitfalls well illustrate a common saying among medical scientists: “The plural of anecdote is not data.”
The difficulties with isolated case reports are not unique to medicine. Consider something like an internet message board, most of which are devoted to specific topics. People posting on the board share their experiences and opinions about many things, such as particular products that work or do not work. Vigorous debate often ensues, some of it supported by evidence of some kind, some of it not. But the effect is that of a series of case reports, and readers of the messages have no idea how representative is the experience of an individual poster.
Case reports and series are an example of what is called selection bias — the possibility, or even the probability, that the individual cases have not been selected randomly from the total group they come from, which is all people who have the disease. They are therefore not representative of the entire group, and using them to draw any conclusions about the whole group is suspect. Consider again the example of the internet message board. If thousands of posters complain about a particular product, the odds get progressively higher there is some problem with it. But people with a complaint are probably more likely to post than are those satisfied with the product, so there is built-in selection bias. Additionally, the sample will include only people with internet access and familiarity with message boards. Only a survey of everybody who bought the product, or a properly randomized sample of them, can answer the question.
Whooping cough, or pertussis, its official medical name, is one of those things we hear our grandparents talk about. It once made many, many infants extremely sick with severe coughing and excessive mucous, and some died from it. The so-called paroxysms of coughing can end with the infant sputtering and blue at the end of the spell, after which he takes a huge gulp of air — the characteristic “whoop.” They tire themselves out so much from coughing that they have little energy left to do anything else, including eating.
We have a vaccine that does a fairly good job of preventing whooping cough, which is why we don’t see much of it these days. But the illness has not gone away. In fact, I saw several cases this past winter, one of the many I’ve seen over the years, and there was a recent epidemic from it in California in which several children died. This epidemic was caused by the drop in vaccination rates. That drop came from parents understandable, but misplaced fears over the vaccine. (You can read several well balanced essays about that over at Dr. Wendy Swanson’s (Seattlemamadoc) blog here, here, and here. The comments are particularly useful in understanding the issue.)
The protection the vaccine gives tends to fade with age, and studies have shown that a fair number of adults with a persistent, chronic cough actually have infection with the pertussis bacteria that causes whooping cough. If such people come in contact with young infants, typically before those infants have completed (or even received) their vaccinations, the babies can get the infection. This is why adolescents and adults exposed to infants should get a Tdap booster.
I’ve seen some very severe examples of what can happen then. I described one of these in my first book.
The infection affects children in several ways. Our respiratory tract normally produces mucous every day. This is one of the key ways we protect our lungs from all of the particles in the air, such as dirt, pollen, and dust. When we breathe these particles in, they are trapped by the mucous in our airways, and we then cough the material out, which is why our phlegm looks dark after we have been in a dusty environment. The whooping cough bacteria increase the amount of mucous in the infected child’s airway. In addition to that, the bacteria interfere with how the lungs normally get mucous up from the small airways to cough it out. The result is that a child with whooping couch is nearly drowning and gasping for air between coughs; this gasp at the end of a coughing spell is the “whoop” of whooping cough.
If you are interested in finding out more about this infection, you can find it here and here. If you’re interested in hearing exactly what whooping cough sounds like, there’s a new clip up on YouTube here. It’s an excellent example.
With summer upon us, it is time to talk sunscreen. It is great for children to play in the sun. But, as most parents know, the ultraviolet rays of the sun can cause harm. The immediate potential harm is a painful sunburn; the long-term possible harm is premature aging of the skin and a higher risk for later skin cancer. The way for your child to enjoy the sun safely is to use sunscreen. But buying proper sunscreen is complicated because the labeling of these products can be confusing. Finally, after many years of studying the issue, the federal Food and Drug Administration just laid down the rules of how sunscreen is to be labeled, making it easier for parents to understand the best one to buy for their children.
Ultraviolet light from the sun comes in two forms, called ultraviolet A (UVA) and ultraviolet B (UVB). Sunburn is mostly caused by UVB. UVA can contribute to sunburn, but the main concern with this form of ultraviolet light is skin damage that can lead to premature aging of the skin and an increased risk of skin cancer many years later. Of course you would want both forms of protection for your child, but reading the labeling of sunscreen products has been difficult, and not all products protect equally. The confusion has been over the use of terms like “broad spectrum protection,” “long-lasting,” and “sweat proof” or “waterproof.”
Starting next year, any sunscreen product that claims to be “broad spectrum” – that is, protect against sunburn as well as cancer or premature aging — must block both UVA and UVB. It also must have an SPF (sun protection factor) of 15 or higher. Regarding water resistance, the new FDA rules say that the label must tell you how long the protection will last after wetting the skin – 40 or 80 minutes.
Until these new rules make it to products on store shelves, parents should check to make sure the sunscreen blocks both UVA and UVB and has an SPF value of 15 or higher. Parents should also reapply sunscreen to their children every two hours for the best protection. It is also safest to reapply it after your child has been in the water. And when you send you child out to play in the sun, remember to put a hat on them. Hats are easy, low-tech protection for necks and faces.
You can read much more about the new FDA sunscreen regulations at the agency’s site here.
I was a medical researcher for several decades, investigating an unusual, but not rare, condition called infective endocarditis. I found the disease fascinating, primarily because of how understanding it could unlock many secrets of the endothelial cell, the cells lining all our blood vessels. I chose my research subject because it interested me and I thought I could do some good studying it. This is the case for most medical researchers.
Of course, there are incentives nudging researchers toward working on a particular disease. The main one is research funding. Most of my work was funded either by the National Institutes of Health or the American Heart Association. Both organizations, and others like them, from time to time issue invitations to apply for funding in a particular area, one identified by the organization as being in particular need of special support.
In general, though, the approach has been to let researchers propose to these organizations projects of interest to the investigators and let the funding committees choose the best among them. Directed research, telling investigators what to work on, has been viewed with suspicion; it is best to let smart people work on whatever they think best.
There are good reasons why this is a good default position. Very, very often directed research doesn’t get us answers because the answers often come from unexpected places. I can think of many examples where breakthroughs in understanding a particular disease came from research that, at first blush, seemed totally unrelated to it.
However, a problem with this paradigm is that, if no directed research happens, rare and unusual conditions may remain completely mysterious for years, maybe forever, because no medical researcher happens to be interested in them. Patient advocacy groups have an important role to play in such situations.
There’s an interesting example in a recent New England Journal of Medicine (here and here) of the potential power of these groups. (Unfortunately the full article and accompanying editorial are behind a paywall — I’d be happy to send the full articles to anybody who is interested.) The articles concern a very rare disorder called lymphangioleiomyomatosis, a devastating disease that can strike young women. Because it is so rare, it attracted little attention from medical researchers. Then a mother of a woman with the disease started a patient advocacy group and founded the LAM Foundation. Her tireless efforts attracted some interest, and the money the foundation offered to researchers served as seed money for them to develop grant funding proposals to organizations and agencies with deeper pockets. The LAM Foundation served as a kind of venture capitalist for the research effort. The result of this has been significant strides not only understanding this disease, but useful treatments, too.
I think the other important point to take from this example is that patient advocacy groups should aim to spend most of their precious resources, not on advertising and organizational structure (a chronic pitfall for nonprofits), but on actual research support undertaken on the advice of experts.
(A couple of weeks ago Maggie Mahar, who writes the excellent Healthbeat blog for The Century Foundation asked me for my thoughts about a recent Perspectives piece in the New England Journal of Medicine by Treadway and Chatterjee regarding this question: can empathy and compassion be taught to medical students and resident physicians? She published my reply here — I cross-post it below.)
We want competent physicians, but we also want compassionate ones. How do we get them? Is it nature or is it nurture? Is it more important to search out more compassionate students, or should we instill compassion somehow in the ones we start along the training pipeline? I think the answer lies in nurturing what nature has already put there.
My background is in pediatric critical care, which I have practiced for nearly thirty years. Throughout most of my career I have taught medical students, residents, and fellows. So I have seen young physicians as they made their way as best they could through the long training process. I also served on a medical school admissions committee for some years and interviewed many prospective students, so I have had the opportunity to see and speak with them before the medical education system even got hold of them. After reading Doctor Treadway’s essay, I think my overall perspective on the question is similar to hers – the main principle to keep before us is not so much to figure out a way to teach compassion, but rather to devise ways such that the training process does not reduce, or even extinguish, the innate compassion all humans have toward one another. Unfortunately, our current way of doing things does not do a very good job at that task. But I do not think our present state of affairs is anyone’s fault. We are hobbled by our success. Some historical background is helpful, I think, to explain what I mean.
When my grandfather graduated from medical school in 1901, he had only a few tools to help the sick. He could do useful things to help injuries mend. He had the newly discovered techniques of aseptic surgery, as well as ether to allow him to do it painlessly. Other than that, though, he did not have much – narcotics to relieve pain, powdered digitalis leaf to help a failing heart, and a few other things. Mostly, though, he had bagful of useless nostrums. Some of them were even harmful. Because he had little to offer, compassion figured prominently in whatever therapy he did. It had to.
When my father graduated from the same medical school in 1944, things were better. Surgery had advanced further from his father’s day, although only brave surgeons entered the chest cavity. There was sulfa, and penicillin soon became available, working miracles with previously deadly infections. Streptomycin and later drugs made tuberculosis treatable. He soon had some drugs to treat hypertension, which by then had killed his father, plus a rapidly enlarging stock of other useful drugs to put in the black bag he took on house calls. But there were still many things for which he could do nothing. For a heart attack he gave some morphine to take away the pain and then waited to see what happened. If a cancer could not be removed surgically, he had nothing to offer. Although my father’s black bag held more than his father’s had contained, compassion was still a crucial part of my father’s armamentarium. As for his father, it had to be.
I graduated from medical school in 1978. If scientific medicine was just spreading its wings during my father’s training, I experienced it in full flight. By then our medical-industrial complex had rolled out nearly all of the varieties of therapies we have still, although of course we have polished and improved them. What has happened, I think, is not that we have become less compassionate on purpose, but that we came to act as if we no longer needed the compassion of my father or my grandfather’s era, now that we had so many really useful and exciting therapies to offer.
I also think one other historical change is key to understanding how our young doctors react to the experience of seeing death and dying. In my grandfather’s era, it was an unusual person, even an unusual child, who had not personally seen someone die. Children and young adults saw how those around them behaved and reacted to death. If they became doctors, both they and their patients had shared this common experience, so both knew how to act. I saw death for the first time when I was sixteen on my very first day working as an orderly in our local hospital. I was giving a bath to an old man; he looked at me oddly, and then he was dead. None of my friends or schoolmates had ever seen such a thing. I still recall it vividly. I also remember well how helpful the nurses, all women in their sixties, were to me afterwards. I watched them wash the body, a once sacramental task now largely done by nurses in hospitals instead of families in their homes. They were respectful, but matter-of-fact as they went about it. After all, it was a natural thing.
Getting back to Doctor Treadway’s observation, I agree with her that compassion for others is innate in all of us, although it is stronger in some than in others. All of us possess an inner light. Perhaps that opinion makes my theology show, but I think it is fair to say our medical school selection process already skews toward selecting students more compassionate than the average person. We need to encourage that quality, certainly, but that is not the key issue in my mind; mainly we need to prevent medical training from driving it into the background, belittling it, or even snuffing it out. So I do not think we need so much to ponder how to teach compassion as we need to find ways of letting students’ natural humanity shine through. For medical educators, that would seem to me to be good news. Framed that way, it ought to be doable – but how?
There are many things in medicine that can be taught with the old “see one, do one, teach one” model that those of us older than fifty remember. We also remember never seeing a faculty attending physician in the hospital at night, because, after sundown, the place belonged to the residents. Even during the day, attending physicians were more likely to be found in their offices or their research laboratories than out and about on the wards. I learned how to intubate a baby and place an umbilical artery catheter from my senior resident, who had learned the year before from her senior resident. But my senior resident was not much help when a premature baby died; she was at much at sea as I was. All she had learned about that from her senior resident was to cultivate the kind of hard-boiled persona described by Dr. Chatterjee. We aspired to it partly because it gave us a mental escape hatch in those situations. But mainly it was because nobody showed us any other way.
How to show that other way? In my mind, there is no substitute for senior, seasoned physicians demonstrating, in the moment, how to let out our own innate empathy and compassion. Good, experienced physicians are comfortable admitting their medical ignorance and failures to families; nothing terrifies residents more than that. When they see it in action, students and residents respond with a version of: “that’s why I became a doctor.” Structurally, medical education has already made great strides in the right direction. We now have rules for resident supervision that involve much more oversight, even at night, than I ever had. This was done mostly for patient safety, I think, with education as a secondary but important goal.
So the opportunities are there – we just need to implement them better. For example, after an unsuccessful resuscitation and a death, the folks with the grey hair should spend as much time discussing with students and residents the psychic dimensions of the death as they do the sequence of medical decisions. Most of my colleagues already do that to varying degrees, but it should be an expectation.
We should never again send a resident, alone and emotionally at sea, to comfort a grieving family without backup. We do not do that for complicated invasive procedures; we should not do it for this other, equally important task either. Certainly some organized instruction – seminars, discussion groups, lectures and the like – can be part of the process. But the training curriculum is already stuffed with subjects. Taking residents by the hand and leading them through these experiences does not require another fat syllabus. It only takes a little time. If we want to foster compassion in our students we should ourselves show them compassion for the situations we put them in.
Offhand you would not think a child with severe viral pneumonia and one with a major head injury are much alike, but they are. Together they illustrate a great truth of pediatric intensive care medicine, which is much of what we do is not specific treatment for the child’s problem; rather, it is what we term “supportive care,” because it supports the continued functioning of the child’s vital organs and systems while the problem runs its course and the child heals.
Both of these children often require very sophisticated technology to provide that organ support, things like mechanical ventilators and devices for measuring pressures inside the brain, but that technology doesn’t actually cure anything. But if it doesn’t cure anything, what does it do?
One of the most important principles of supportive care in the pediatric intensive care unit is that we make sure what we are doing does not make the problem worse. A good example of that is the child with a severe head injury. Although there are a few things we do to help the situation, a key aspect of what we do is the maneuvers we go through to make sure the brain is given a chance to heal without further stresses. For the child with severe pneumonia, the sort of child who is often on a mechanical ventilator machine, we do a similar thing — we use the machinery in such a way to minimize the chances that the ventilator itself does no harm, although this is not always possible.
This kind of watchful waiting at a sick child’s bedside is something parents have done for millennia. What the PICU often offers is simply an updated version of that time-honored vigil.
This is another post about how non-physicians can understand how physicians use evidence. As I noted before, medical evidence has a hierarchy of reliability. The least reliable of these is expert opinion. This seems counter-intuitive: why is expert opinion the worst sort of evidence? Should not the experts know what they are talking about? In general, of course, experts do know what they are talking about — that is what makes them experts. But a closer examination of the matter shows why this kind of evidence is the weakest and most subjective; after all, it is one person’s opinion (or sometimes a committee of persons’ opinions), and opinions can be incorrect.
We need to look closely at just why a particular individual is considered an expert, and by whom. Credentials are important: where did the person obtain her training, where does she work now, and what is her standing among her peers? These seem obvious questions to ask, but these days an astonishing number of people with dubious or no credentials can write a book, put up a website, or start a blog, and, if they are persuasive marketers, can convince others they are experts. Fortunately for parents, the same wide-open quality of the internet allows one to search the background, credentials, and accomplishments of any putative expert. Wise parents will do this as a matter of course before deciding whether to take the expert’s advice on any important matter about their child’s health.
Experts who advise you to do one thing or another with your child typically base their advice to you on their own interpretation of the available medical research. They have the knowledge and training to understand the often esoteric medical literature. In addition, most experts themselves do research in the relevant field. Those are important and useful things. However, there are still good reasons why we should regard such opinions as the worst kind of data — better than nothing, but sometimes only barely so.
For one thing, the reason an expert holds a particular opinion may be because she was taught that way by her teachers, who may have, in turn, been taught the same thing by their teachers. Medicine is practical and empirical enough that such received, traditional opinions will not be tossed out unless they are consistently wrong. It is also true we physicians venerate our medical forebears to the extent that misguided opinions can occasionally persist long after they should have been discarded. So sometimes the answer to why doctors do something a particular way is that we have always done it that way.
Experts also form their opinions based upon what they have seen in the past. If their experience is long, often they have seen quite a few instances of whatever is under discussion, and that experience should count for something. On the other hand, memory is a tricky thing; sometimes we recall things in ways that can ultimately prove misleading. For example, the more striking and dramatic things tend to stay in our minds better than the more mundane things, and medical experts are not immune to this phenomenon. For example, I know that I remember unusual manifestations of certain cases for decades, and this inevitably colors how I approach the next child with that particular problem. Even though I know the case was unusual, I naturally think of its circumstances whenever I care for another child with whatever the disorder was. This is an example of what we call recall bias.
There are other kinds of bias that may affect the judgment of medical experts, and some of them are not innocent things like tricks of memory. Medical experts are no different from other kinds of experts, such as foreign policy pundits or stock market analysts, in that we, too, may have agendas that are not obvious to parents listening to our advice. Any controversial subject will lead to partisanship, and medical debates are no different. Parents considering the advice of medical experts should be alert to what a particular expert’s agenda might be. This is not necessarily a sinister thing; I think the great majority of experts advocating one position or another do so because they truly believe it is the correct one. But it is still a real thing.
Sometimes, however, medical experts may have agendas that are not so innocent. For example, there have been recent examples of experts touting one treatment over another when they have an undisclosed interest in the outcome. The conflict of interest could be intellectual, such as past friendships or associations with researchers of a particular treatment, or they could be crassly commercial. The ethical boundaries are, in theory, quite sharp, but there have been well-known examples of medical experts recommending a particular treatment when they have a financial conflict of interest regarding the outcome.
The best experts, of course, are the ones who tell you the basis of their opinions. They do not just pontificate about what is best for your child — they tell you how their reading of the best evidence led them to their informed opinion. They interpret for you the meaning of the scientific evidence. On the whole, most medical experts will do this for parents. Even so, it is a good thing for parents not to take whatever the experts say entirely on faith; it is better to have some grasp of how medical evidence is collected and analyzed. And besides, even experts can be wrong.
Over the next month I’m going to repost a series I did about how to understand medical evidence — how to read the medical news. How can a non-physician interpret the latest breathless bulletin about some new breakthrough? Are there commonsensical tests one can apply to the story to see how valid it might be? There are. One useful notion is that we have ways of grading the validity of different sorts of evidence. I’ll get to those in later posts. First, it is useful to know where we’ve come from.
Medicine is not totally a science. It makes use of science and struggles as best it can to adhere to scientific principles, but medical knowledge, perhaps because it involves humans, will always contain an element of human fallibility. This is more true of some aspects of medicine than others. For example, we understand the science of how a damaged bone heals far better than we understand the science of how a damaged mind does. Medicine is occasionally more or less science-inspired intuition. A good share of the frustration non-physicians have with medicine stems from this misunderstanding of what medicine fundamentally is. Yet in spite of all the inherent vagaries of medical practice, the fact remains: we can know things, there are tools to help us do this, and these tools are based on the scientific method.
Throughout most of its history medicine had no scientific footing at all, and for centuries it was as much a branch of philosophy as it was anything else. The theories of how the body worked were fanciful notions with little or no basis in observed reality. The Scientific Revolution changed that. Ever since William Harvey decided in the early seventeenth century to test thousand-year-old teachings of how the blood circulated by actually looking at what happened, the principle of experimental observation has been a foundation of medical science. Although the accepted ideas of disease causation remained outlandish to our modern eyes for many years after Harvey’s pioneering experiments, the world of medicine had still changed profoundly and permanently. Henceforth the best physicians would actually test to see if their theories had any basis in observed reality.
For Harvey and the thousands of medical researchers who came after him, if they had a theory about how the body worked, they tested it with experiments. But it is also important to understand we can use sound principles of scientific observation even when we have no idea, no theories, about why things happen. For example, we can compare two ways of treating a disease though we have no notion of what causes the disease. It is often the results of such naïve observations which lead to theories of disease causation, theories which can then be tested with further observations. But we can still reach some useful conclusions about what works and what does not work without having any understanding at all of the reason why.
The vital distinction to make is this: although we can have good observations without underlying theories, we cannot have useful theories that are not based upon some kind of valid observations. What does this principle mean for today’s parents? From the outset, parents should demand of anybody making a claim about how children’s bodies work that they show good evidence in support of their theories. And good evidence can be hard to find.
The physicians of Roman times, whose theories Harvey disproved, saw no need to provide any experimental evidence at all. These days parents hear conflicting evidence everywhere; all the partisans in these debates have evidence. The problem is to decide among the conflicting claims whose evidence makes sense and whose does not. Can parents do that? Again, without the need to make a biostatistician of anyone, I believe they can. What they need to learn, and then practice, is how to look critically at medical claims.
The first step is to understand that not all evidence is equal, even if the people collecting it wear a long, white coat and have degrees after their names. Like good detectives, we need to weigh the validity of different kinds of evidence, and medical scientists have established a hierarchy of kinds of evidence to help decide which is the most likely to be correct. The hierarchy runs from least reliable to most likely to be right. Parents may be surprised to learn the least reliable category is expert opinion, what an individual expert or even a committee of experts say is correct. Next in believability comes various forms of what are called uncontrolled studies, and most reliable are what are called randomized, controlled trials (RCTs).
You will read about the first of these, expert opinion, in the next post.
From time to time have children, mostly toddlers, in the PICU who are there because of an overdose of a medication meant for somebody else. I frequently see this scenario happen: parents are careful to keep all medicines locked away from curious toddlers, but then the child visits grandparents who, not having small children regularly around the house, are not so diligent. Many older persons take one or more of a wide variety of powerful medications that can cause serious or even lethal poisoning in small children. Child-proof caps are sometimes difficult for the elderly to open, so they may not use them. I deal with the results of what this can lead to at least several times each year. A parent whose small child spends significant time at another house, especially if someone living there takes medicines, should make sure those medicines are stored safely. Toddlers are amazingly quick at getting into trouble.
The best and fastest way to get advice about poisonings in children is to call your regional Poison Control Center. To make this easy to do, the telephone number is the same across the nation: 1-800-222-1222.