Wednesday, May 23, 2018

Antibiotics: Your Choice or Everybody’s Business?

By Sarah Freymann Fontenot, BSN, JD, CSP
Written with Charles (“Bud”) F. Brummitt, MD

We all know antibiotics are fairly standard treatment — and all of us want to make medical decisions with our physician in the privacy of the exam room.

Whose business is it if you are given an antibiotic you don’t really need?

All of ours.

Let’s say you (or your kid) has the flu — and you really want an antibiotic. The problem is that the flu (and most colds) is caused by a virus — which couldn’t care less about an antibiotic.

Antibiotics only kill off bacteria — so your new drug will happily set off to kill many of the good bacteria in your system — like the kind that help you digest food and do other things you are fond of.

In the meantime, some of the bacteria in your system will fight back and grow resistant to the drug. Over time these antibiotic­resistant bacteria spread through you, your family, and your community.

It gets worse. Antibiotics are also given to animals being raised for food. There is some controversy over how much this happens (see below). Many advocates for our agricultural industry acknowledge that antibiotics used solely for growth promotion of animals, rather than to treat infections in those animals, need regulation.

When these animals are given antibiotics, their system also produces stronger, more resistant bacteria — which we eat. As a bonus, when their manure is used to fertilize fields, our fresh fruits, vegetables, and other crops are exposed to the mutant bacteria, too.

Over time our world has used antibiotics — one of the greatest developments of modern medicine — in a manner that has led, ironically, to bacteria we can’t treat.

Sometimes the bacteria are associated with the most common infections (such as pneumococcus, which causes many child ear infections), but these ninja bacteria can get very, very scary. If you want three good horror stories take a look at MRSA; antibiotic­resistant gonorrhea;  and the E. coli bacteria known as O157:H7, which has been associated with many dozens of outbreaks of contaminated food from lettuce to burgers and other foods, and which can cause life-threatening symptoms. (And although it is rarely due to resistant organisms or prior inappropriate use, I have to give a shout-out to the media favorite necrotizing fasciitis, caused by flesh­eating bacteria).

Here Is the Problem — No One Thinks He or She Is the Problem

I truly do not think doctors actively overutilize on purpose, and I do not think patients demand drugs that will hurt them and their communities.

But this is where this issue gets really interesting.

A finger can be pointed to certain regions of our country. As this map from the Centers for Disease Control and Prevention so brilliantly illustrates, there are vast differences in how frequently antibiotics are used in different states. This would suggest that the level of utilization is based on regional culture as much as medical need.

Find your state and see what your cultural attitude about antibiotics is. Are you sunshine yellow? Then your attitude about antibiotics likely will be different from a person’s in West Virginia or Kentucky — the states with the highest utilization of all (at least that was true in 2011).

Are people in Indiana sicker than those in Illinois? Do all the extra antibiotics in the Deep South make those populations healthier than Californians?

My point is certainly not that the physicians of Wheeling or Bowling Green are worse than the doctors of Santa Barbara. I am also not saying the doctors in California always get it right, but looking at the averages is quite striking.

It appears that “normal utilization” looks different to people in the redder states: both the physicians ordering more antibiotics and the patients requesting them.

What Can We All Do?

No one is suggesting you fail to follow your doctor’s orders, and it would be silly to start thinking of antibiotics as bad things. But there are steps every one of us can take that will help stop the growth of resistant bacteria.

When you get an antibiotic, take it exactly as ordered, as long as ordered (cutting your treatment short, say to only six days when your doctor said 10, also fosters mutant bacteria). Don’t hoard antibiotics, and don’t take them without an evaluation to see if you have a bacterial illness that would even respond. You also should never share your antibiotics with others.

Perhaps most of all: Stop asking for them. If you need one, you will be told that you do.

What Is Antibiotic Stewardship?

I want to close with my friend Charles (“Bud”) F. Brummitt, MD, who chairs the Antibiotic Stewardship program at Aurora Health Care in Milwaukee, because he says it best for me:

“Antibiotics are the only class of drugs that if we misuse can jeopardize not only our own health but also those around us. Because bacteria can become resistant to antibiotics quickly with use, it is imperative that we use them judiciously and appropriately to preserve their usefulness and lessen the chance they will be ineffective when we and our loved ones need them.

“If you misuse your blood pressure medication you only hurt yourself. But with antibiotics we are all collectively hurting everybody.

“Antibiotic stewardship is educating the medical community and all of society to protect us from losing major successes in health care, such as immunizations, and antibiotics themselves. It is a lesson we all need to take to heart — for ourselves, our children, and all that follow beyond.”

I sincerely hope you all hear those words as a call to action — to all of us, and for all of us.

Wednesday, May 16, 2018

Maternal Deaths in Texas: Let’s Go in a New Direction

By Erika Munch, MD
San Antonio obstetrician-gynecologist, reproductive endocrinology and infertility specialist

Texas leads the country in many categories.

Friendliest people? Check!

Tallest 10-gallon Stetsons? Check!

Maternal mortality? Reality check.

Maternal deaths in Texas, defined as deaths during pregnancy or in the first six weeks after delivery, have some of the highest rates in the county and the industrialized world — close to 30 deaths per 100,000 live births. Nationally, the United States has a maternal mortality rate of about 28 deaths per 100,000 live births, which is nearly 50 percent more than in 2005 and more than double the rates of Canada and most industrialized European countries. In 2012, there were some widely publicized but erroneous numbers of Texas maternal deaths (mainly because some unrelated causes were included). But regardless of the exact number, even one preventable maternal death is one too many.

Several smart people have gotten together to serve on the Texas Department of State Health Services (DSHS) Maternal Mortality and Morbidity Task Force to best determine how to decrease these numbers, paralleling nationwide efforts to decrease maternal deaths. In a recent national study published in the professional society journal Obstetrics & Gynecology (The Green Journal), several Texas investigators examined what pregnancy factors may be linked to higher risks of maternal mortality. Most factors they identified can be sorted into three broad categories:

  1. Limited access to care — Maternal mortality was linked with unintended pregnancies and limited prenatal visits, meaning women who weren’t intending to be pregnant or could not access a doctor for prenatal or postpartum care were at higher risk of dying.
  2. Previous health problems — Diabetes, elevated blood pressure, obesity, and heart disease can make a pregnancy and the first six weeks postpartum riskier.
  3. Race — Certain groups, including Hispanics and non-Hispanic black women, are at higher risk of maternal mortality, possibly because of limited access to care or preexisting health problems.

So what’s a Texan to do? Friendliness and stylish hats are not going to get out of this one. Fortunately, the task force is developing recommendations, some already in place, to help reduce these risk factors. I’ve summarized the recommendations below.

  1. Get the facts! Provide preconception education
    This starts with providing access to family planning services like providing contraceptives and education to women who are not yet ready to be pregnant. Campaigns like Someday Starts Now aim to educate women about the risk factors THEY can change, without a doctor visit, that affect the health of the mother and infant. These include avoiding secondhand smoke, achieving a health body weight, and proper nutrition.
  2. Know before you go! Manage preexisting conditions
    If you are thinking about pregnancy, get a physical! Pregnancy is the longest cardiac stress test that most of us ever endure, much more demanding than five minutes on a treadmill. Cardiac events (like heart attacks or heart failure) were the No. 1 cause of maternal death in Texas in 2011-12. A primary care physician or obstetrician-gynecologist can help you or your loved one get on track to manage any health conditions, like diabetes and high blood pressure, as well as the “silent” conditions like heart disease, which can cause life-threatening complications in pregnancy if not well managed.
  3. Give mom a hug! Support women postpartum
    After all the weekly pregnancy visits are done and the baby is born, all eyes are on the baby! But as a society, it’s a grave mistake to ignore the changes that happen to mom in those first few weeks (and unfortunately, a mistake that most new moms make themselves). Mom’s risk of blood clots, stroke, and cardiac events generally increase in those first six weeks after she gives birth. The risk of postpartum depression exists, too, which can decrease mom’s ability to get other health matters evaluated, and can isolate new moms even further. So give that new mom the encouragement she needs … maybe it’s a hug, maybe it’s a clean and convenient place to pump milk once she returns to work. And if you’re someone who carries professional or legislative pull, consider advocating for or enacting some laws that protect moms and extend health care access well into the first year after birth. 

Together, we can all do our part to take care of Texas, especially caring for those who are growing and raising the future of Texas.

Editor’s Note: In March, physician leaders met at TMA’s Maternal Health Congress to discuss ways to reduce maternal deaths. They will present their proposals to the TMA House of Delegates (the association’s policymaking body) this weekend at TexMed, TMA’s annual conference in San Antonio.

Thursday, May 10, 2018

The Best Mother’s Day Gift

By Dr. Carlos J. Cardenas, MD
Edinburg Gastroenterologist
President, Texas Medical Association

This article was originally published in TribTalk by The Texas Tribune.

What better Mother’s Day present could Texas give than a commitment to making motherhood safer? And that’s just what Texas physicians are doing.

Despite some recent confusion over the exact numbers, there is no question that pregnancy, delivery and the first year after giving birth are much too unhealthy for Texas women — especially Texas women of color.

We talk about “maternal mortality and morbidity.” But remember this: “mortality and morbidity” are just high-sounding words for “death and disease.” As physicians, we fight death and disease every day — for children, for car crash victims, for the elderly and for the millions of Texans who live with chronic ailments like diabetes and heart disease.

And we fight death and disease for our mothers.

That’s why the Texas Medical Association (TMA) convened its Maternal Health Congress. It comprised the state’s leading experts on these problems — and the potential solutions. The congress heard 36 proposals and adopted a seven-point plan to make motherhood safer in Texas. It calls on all of us — physicians, state officials, lawmakers and you — to help deliver this Mother’s Day present.

Here are the high points:

  • Ask Texas to request a federal waiver so we can build a tailored health benefits program for uninsured women of childbearing age. This program would provide the kinds of health care — including primary care, behavioral health care, preventive care and specialty care — to keep Texas women healthy before, during and after pregnancy.
  • Have TMA develop a formal education program to help Texas physicians better recognize and find treatment for women with substance use disorders. This must be a priority as drug overdoses are the leading cause of maternal death in Texas.
  • Eliminate unnecessary barriers and red tape preventing women from easily obtaining the most effective forms of contraception: intrauterine devices (IUDs) and implants. As the Maternal Health Congress report states, “Increasing women’s ability to plan and space their pregnancies leads to lower abortion rates, improved infant and maternal health, educational and economic opportunities for women and their families, and cost savings for the state.”
  • Have TMA develop a formal education program for physicians, nurses and hospitals on the best practices proven to prevent death and disease among women during and after pregnancy.
  • Have TMA develop a campaign to educate the public on how women can make motherhood safer by taking better care of themselves before they get pregnant, getting early and timely care when they become pregnant and knowing where to find help after their babies are born.

This plan goes before TMA’s House of Delegates next week in San Antonio. I am confident it will pass.

If you are lucky enough to still have your mother with you, please give her the flowers, or chocolates or dinner out that you had planned to give. And then tell her you are joining with Texas physicians to give the best Mother’s Day gift ever.

Wednesday, May 2, 2018

Infertility Is a Disease — Let’s Treat It as One

By Erika Munch, MD
San Antonio obstetrician-gynecologist, reproductive endocrinology and infertility specialist

As a reproductive health physician, I hear all sorts of explanations for why people haven’t been able to conceive — most often from patients themselves, who have gotten advice from the internet or from well-meaning but uninformed relatives.
“Sweetie, you just need to try a little harder. And relax! It’ll just happen!” 
“It’s because you had that bad Pap smear that one time. Now it’s caused a problem.” 
“He went around with too many girls when he was younger. No wonder things aren’t happening now.”
Would you tell your diabetic Aunt Thelma she should just relax and see if her blood sugar goes down? Or blame a cancer diagnosis on neglecting to write a thank-you note?

Infertility isn’t a mystery. It’s a diagnosis. It’s a real one that affects about one out of every eight couples trying to conceive. And we ought to treat it as the disease it is — with timely diagnosis and access to effective treatments.

It starts with awareness. If you haven’t been able to conceive after trying for six to 12 months on your own, speak up. Make sure your doctor listens! If you know there might be an issue because of your medical history, seek medical advice sooner rather than later. Listen to your gut, and ask YOUR physician — not Dr. Google, and not “Dr.” Aunt Thelma.

And it continues with activism. Unlike other states with more expansive coverage, Texas is a “mandate to offer” state. Meaning: State law requires group insurers to offer fertility treatment coverage for purchase, but does NOT require employers to purchase that coverage or make it available to their employees. Some employers do cover this for their employees, but unfortunately, many do not.

If infertility benefits are not offered by your company, ask why, and begin the conversation! Often employers are just as unaware as Aunt Thelma of how common infertility really is and the simplicity and cost-effectiveness of available treatments. Using resources from (a nonprofit organization that provides support and advocates for people facing infertility) show your organization that several top companies provide this coverage for their employees in their holistic approach to building a pro-family, productive work environment.

Doctors and patients are united in this front. Infertility is a treatable disease, and we are here to help support your journey to parenthood.

And one day, maybe Aunt Thelma can come babysit.

Thursday, April 26, 2018

Too Many Shots? Choose On-Time to Protect Your Child

Elizabeth Knapp, MD, Austin pediatrician
TMA Be Wise — Immunize Physician Advisory Panel member

As parents, we all want to make the choices that protect our children. Getting infants’ shots on time, based on the recommended schedule, is the best way to protect our babies from the risk of disease. As a pediatrician taking care of many precious babies over the years, I often am asked whether there are too many shots. Some parents wonder if we can safely protect against so many illnesses. I tell them it is true that the current vaccine schedule protects against a number of strains of different bacteria and viruses. Vaccinating on time is safe and gives our babies protection against horrible illnesses as early as possible.

As a mom, I know there are so many decisions to make. Between diapering and feeding decisions (breastfeeding vs. bottle) to thinking about our child’s future, the choices can be overwhelming. Luckily, the choice of what vaccines to give your child and when to give them has been tested and evaluated by many, many scientists. They have evaluated the way infants’ bodies respond to vaccines to make sure they will protect babies against illnesses that can be deadly.

To get lasting protection from the vaccines, infants need to receive multiple booster doses. These booster doses essentially boost the body’s memory, giving children protection from diseases for years to come. Because babies need repeated booster doses, completing the vaccinations on time is difficult when vaccines are spaced out. It means many more visits to your doctor’s office than the typical seven visits in the first 12 months of your baby’s life.

Parents ask me if infants really are able to handle so many vaccines at once. Some parents worry the vaccine components needed to protect against so many diseases are too much for babies’ little bodies. But our infants, from the moment they are born, are exposed to thousands of substances they are developing protection against. And their immune system is working hard from the time they are conceived to help them be ready. Vaccines help their little bodies accomplish this protection.

It’s true that babies receive more vaccines today than their parents did as children 20-40 years ago. But our newer vaccines contain less of the ingredients that trigger the body to develop more resistance, or immunity, to disease. So even though children today are getting more vaccinations, they actually are getting less vaccine elements to spur a stronger immune response. Our vaccine technology has improved over the years. Scientific studies of vaccination schedules have shown infants do not have weaknesses in their immune system after they get their vaccines. Tests also have analyzed babies’ response to receiving several vaccines together. Giving several shots together does not weaken their body’s response to any one particular vaccine.

Our vaccines are safe. Not giving them on schedule leaves babies vulnerable to sicknesses, such as brain infections and deadly cough illnesses. We all want to protect our babies; thank goodness we have that choice.

Wednesday, April 25, 2018

The Texas Department of Family Protective Services Brings Hope to the Efforts Against Child Abuse

By Courtney Welch, MD Candidate
Texas Tech University Health Sciences Center School of Medicine, 2019

April is National Child Abuse Prevention Month. Over the past few years, Texas has made a tremendous effort to address the poignant issues surrounding child abuse and neglect. Great thanks goes to Judge Janis Graham Jack (senior United States district judge of the U.S. District Court for the Southern District of Texas). The attention she brought to the flaws in the Texas foster care system resulted in drastic changes to the state’s policies and infrastructure.

Now the Texas Department of Family Protective Services (DFPS) and its Prevention and Early Intervention (PEI) division are beginning to implement and review these changes, and are being rewarded with measured success. However, the need for evidence-based recommendations and research-confirmed results is still great. Below is a review of past mistakes, an overview of present efforts, and a projection for the future regarding Texas’ attempt to tackle one of the most daunting issues facing children today.

An Acknowledgement of Historical Need

Only three short years ago, Judge Jack accused the state of Texas of violating children’s constitutional right to be free from harm while in custody. The investigation and ruling were prompted by an alarming number of deaths as a result of child abuse and neglect. In 2015, Texas saw 171 confirmed cases of child death due to maltreatment or neglect, some of these occurring while children were under the care of the state. Though this number was down from the all-time high of 280 deaths during 2009, Judge Jack accused the state of Texas of having a broken system. She demanded reform.

The ruling sent a shockwave through Texas, prompting the state, and especially DFPS, to make swift changes. Since 2015, the DFPS has made incredible strides — in great thanks to the efforts of the PEI division. PEI houses the Office of Child Safety, oversees the Texas Home Visiting Program, and works with other community programs and nonprofits around the state. Its mission is “[to help] create opportunities for children, youth, and families to be strong and healthy by funding community-level, evidence-informed programs and systems of support upstream from crisis and intensive interventions.” Simply stated, its goal is to work with communities to intervene before child abuse happens.

An Overview of Current Efforts

After Judge Jack’s 2015 ruling, PEI set itself to work on a five-year strategic plan, published in 2016. The plan created the following seven overall goals:

  1. PEI will adopt a public-health framework to prevent child abuse and fatalities and support positive child, family, and community outcomes. 
  2. PEI will maximize the impact of current investments and seek additional resources to serve more children, youth, and families and strengthen communities. 
  3. PEI will make and share decisions about investments in families and communities based on an analysis of community risk and protective factors as well as community-developed needs assessments. 
  4. PEI will utilize research findings to improve program implementation, to direct program funding toward the most effective programs, and ultimately to achieve better results for children and families. 
  5. PEI will measure and report on the effectiveness of its programs on an annual basis and will make timely course corrections based on available data.
  6. PEI will maximize its impact by collaborating with other state entities and external organizations working with similar populations. 
  7. PEI will be transparent and inclusive in its planning and operations and will proactively publish its strategic plan and progress towards its goals.

Communities around Texas can feel the presence of PEI through programs like:

  • Community-Based Family Services, 
  • Community Youth Development,
  • Fatherhood-oriented programs (such as Fatherhood EFFECTS),
  • Home Visiting, Education and Leadership (HEAL), 
  • Help for Parents, Hope for Kids (Help & Hope), 
  • Helping Through Intervention and Prevention (HIP), 
  • Healthy Outcomes Through Prevention and Early Support (HOPES), 
  • Military Families and Veterans Pilot Prevention Program, 
  • Texas Nurse-Family Partnership, 
  • Safe Sleep Public Awareness Campaign (Room to Breathe),
  • Safe Babies Evaluation, Service to At-Risk Youth (STAR),
  • Statewide Youth Services Network, 
  • Texas Families Together and Safe, and
  • Texas Home Visiting Program. 

Each of these organizations is specifically paired with a research and evaluation partner — usually a department in an institution of higher education — that reviews the goals of PEI in relation to the program, summarizes the program’s outcomes, and makes recommendations for improvement. A review of the previous fiscal year — as well as business strategies for the upcoming years — are published each year by PEI on the Texas DFPS website as is more information about PEI and its associated programs.

A Charge for the Future

The changes and growth in DFPS and its PEI division have played a substantial role in how the state addresses the public health issue of child abuse and neglect. Many agencies associated with PEI have worked tirelessly with the division to set measurable goals in answer to the charge Judge Jack placed upon the state in 2015. Many of these brainstorming efforts have led to good and noble ideas.

But good ideas without plans and the means to execute them are just dreams with no promise of accomplishment. The Texas Legislature moved in the right direction by offering financial support to many of the aforementioned programs under PEI, increasing funding by more than $25 million from 2016-17 to 2018-19. With these funds, DFPS and PEI have increased their capability to serve their mission, but the final question DFPS, PEI, and lawmakers must ask themselves is, “Are we making a measurable and positive difference in the lives of families and children in Texas?”

Remember: At stake here is not just public approval or taxpayer dollars but also the health and lives of children. Therefore DFPS and PEI must implement a solid plan based on evidence of its efficacy. There are not enough funds to ensure the policymakers’ dreams do not become another child’s nightmare. It is tempting to set goals, measure accomplishments, and stop when those tasks have been completed, but it has never been more important to resist the urge to self-congratulate in the face of assumed achievement. The work does not end when the checklist is complete. The need to edit, refine, reframe, and execute new and improved plans will never fade where child abuse and maltreatment is concerned.

To further emphasize the necessity of continued monitoring and revision, it should be noted that this is not the first time Texas has made sweeping changes to its foster care system. One of the most disheartening discoveries in Judge Jack’s 2015 ruling was reviewed under the Findings of Facts and Law section. This section noted that in 2009, then-Gov. Rick Perry commissioned a committee to review and make recommendations on the Texas foster care system. That 2009 committee proposed 14 recommendations in response to its review. After its proposal was completed, the committee unearthed a 1996 report from a similarly charged committee under the direction of former Gov. George W. Bush. The 2009 committee found that 11 of the 14 recommendations it had just written were nearly identical to recommendations made in 1996. This finding effectively accused a well-meaning system of failing our youth. Since 1996, all the wishful thinking, recommendations, and even executed plans had not changed some of the broken system’s underlying flaws.

This time around must be different. It is up to us — as legislators, policymakers, community leaders, health care workers, parents, and Texans — to be honest and critical with ourselves. We cannot wait for another Judge Jack to hold up a mirror to us so we can see our ugly reflection once it is already too late. We must admit that trial is rarely without error and that mistakes will be made. We must be humble enough to acknowledge our weaknesses and courageous enough to make changes for the future.

7,311,923 Texans are children. 66,721 of them are confirmed victims of child abuse and neglect. 17,151 Texas children are placed in substitute care, according to the 2015 DFPS Databook. Children cannot speak or act on behalf of themselves. So now I ask you with a spirit of hope and a hunger for positive change: Are you willing to be their advocate?

Special thanks to Desiree Ojo, Texas Tech University Health Sciences Center candidate, 2019, dual-degree master’s in public health and public administration, who shared with me for this article resources and research she has gathered in preparation for her upcoming round table, Saving the Texas Foster Care System: A Special Panel. Find out more information about the panel and Facebook live stream on May 8, and join the discussion.

Tuesday, April 17, 2018

Is Your Home Safe for Your Child?

The Top Five Ways to Protect Your Child at Home

By Celeste Caballero, MD, San Angelo
TMA Hard Hats for Little Heads Physician Advisory Panel

Did you know accidents at home and in the car are the most common cause of infant/child injury or death? In my medical practice as a pediatric doctor, I talk with parents every day about safety in the home during well-child exams. I do this because safety is a big deal, and accident prevention is key. April is Child Safety Month in Texas, and these are the top five tips I give parents to make their home and car safer:

Dr. Caballero fits helmets on children during a TMA Hard Hats for Little Heads helmet giveaway event.
  1. Protect from falls! Falls are the leading cause of injury to children between the ages of 0 to 19 nationwide, sending some 8,000 children to the emergency department (ED) daily. Always make sure your child wears a well-fitted helmet when on a bike, scooter, skateboard, or skates. And check that surfaces under playground equipment are soft — sand or wood chips — and not hard like grass or dirt. Always supervise your child around stairs and playground equipment.

  2. Buckle up! Every hour, nearly 150 U.S. children are seen in the ED for injuries suffered in a car accident. Make sure you are using the correct car seat, booster seat, or seat belt for your child. Follow these guidelines to find out if you’re using the right one based on your child’s weight, height, and age.

  3. Lock it up! Two children die and more than 300 children are treated every day in the ED for poisoning by household cleaners and medicines found in many homes. Children are curious, and will eat or drink almost anything. Keep medicines, household cleaners, and detergent pods in their original packaging and put them in a place a child can’t see or reach. Post this Nationwide Poison Control phone number on your refrigerator: (800) 222-1222.

  4. Watch the water! Drowning is the leading cause of death in children ages 1 to 4 years old. A child can drown quickly and quietly. Also, floaties don’t prevent all drownings. Adults should take turns watching children every minute they are in a bathtub, pool, or other body of water — and parents should avoid distractions like talking on the phone. Make sure your child has a life jacket on at all times in and around lakes or the ocean, even if they know how to swim. Put a life jacket on a weaker swimmer in the pool. Install a four-sided fence around your backyard swimming pool with self-closing and self-latching gates.

  5. Guard the flame! Like poisoning, burn injuries send 300 children to the ED and claim the lives of two children daily. Closely supervise or restrict a child’s use of the stove, oven, hair curling irons, and clothing irons. Make sure you have smoke alarms on every floor of the house and near all bedrooms, and remember to test them every month. Set your water heater to 120° Fahrenheit or lower to prevent burns from hot water in the bath or sink.

The home, meant to be a place of love and nurturing, can be a very dangerous place for your child. With careful attention, you can make your home safer and help your child avoid an ED visit. Now that’s smart parenting!

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