Dr. Jon Poling to Dr. Steven Novella: Don't Attack the Moms

Managing Editor's Note: The following is a letter sent to Dr. Steven Novella, a neurologist at Yale University, from Dr. Jon Poling. (We've printed the letter with permission.) Dr. Novella is the founder of The New England Skeptical Society (meetings, 1st Tuesday of the month, on the lawn of the House of the Seven Gables, Salem, MA. BYOB (bring your own blinders.) and is a contributing editor to Quackwatch. Dr. Poling is a neurologist/PhD and the father of Miss Hannah Poling.

Dear Dr. Novella,

Your assertion that the scientific question of Autism etiology belongs to the medical community rather than Hollywood Stars is correct.  I also agree that Hollywood opinions are more likely to be broadcast to millions because of their position in the media.  This heightened awareness is nothing but a positive thing for the million families struggling with this difficult, and all too common, disorder.  Jenny McCarthy is an Autism Mom looking for answers and rattling some cages—good for her.  Amanda Peet is a new mom who believes in the importance of vaccines to protect her baby—good for her too.  Don’t attack the moms, listen to them.   

These issues are very complex as we exchanged before and not amenable to soundbites.  Regarding your entry on Hannah’s case, your blog entry unfortunately propagates several of the mistakes from the media.

In criticizing the journalism of Mr. David Kirby, you wrote:

“He refers again to the Hannah Poling case, a girl with a mitochondrial disorder who developed a neurodegenerative disorder with “features of autism” after getting a fever from vaccines.”

Actually—Hannah has diagnoses of DSM-IV Autism (by JHU/KKI psychology) and mitochondrial disorder (by two metabolic experts).  The only ‘degeneration’ that occurred (along with 6mos of total growth failure) after 18mos of NORMAL development followed vaccination and nothing else! Of course, any ‘scientist’ can obviously point out that temporal correlation in a single case never proves causation. Rule number one of pediatrics though is “LISTEN TO THE MOM.”  Are 10s of thousands of autism moms over the last decade suffering from mass hysteria induced by Hollywood?  Not likely.

You also noted:

“This special case - which is not a case of autism being caused by toxins in vaccines - says nothing about the broader vaccine-autism debate.”

The only thing unique about my little girl’s case is the level of medical documentation—5 to 20% of patients with ASDs have mitochondrial dysfunction.  Many other cases where mitochondrial testing is WNL is because "we never looked" not because the testing would be "within normal limits."  Most mitochondrial experts will tell you that the dots of autism and mitochondrial disorders are strongly connected.

Finally, you say:

“The case was settled (not judged in Poling’s favor, but settled) because both sides realized it was a special case that could not be extrapolated to other vaccine-autism cases.”

The case was not settled, it was conceded by medical representatives of Sec HHS.  We are obviously pleased with the HHS decision to concede our case, but we had NOTHING to do with the concession.  This was a unilateral decision from HHS (recall that HHS is the respondent, rather than the vaccine maker, as manufacturers have blanket liability protection afforded by the Vaccine Injury Program established in 1986)  I will not speculate on the obvious question—why concede?   Hannah’s case was positioned to set precedent as a test case in the Omnibus Autism Proceedings for potentially thousands of other cases.

With regard to the science of Autism, I have no argument with the assertion that a single case does not prove causation of a generalized autism-vaccine link.  What the case does illustrate though is a more subtle point that many physicians cannot or do not want to comprehend (ostensibly because vaccines are too important to even question).  Autism is a heterogeneous disorder defined by behavioral criteria and having multiple causes.  Epidemiological studies which have not found a link between autism and aspects of vaccination do not consider the concept of autism subgroups.  Indeed, in a heterogeneous disorder like Autism, subgroups may indeed be ‘vaccine-injured’ but the effect is diluted out in the larger population (improperly powered study due to inability to calculate effect size with unknown susceptible subpopulation).   I think former NIH Director, Dr. Bernadine Healey explained it best in that population epidemiology studies are not “granular” enough to rule-out a susceptible subgroup. 

Furthermore, ‘science’ has not systematically studied the children who fell ill following vaccination to determine what the cause(s) for their adverse reaction was.  It would follow that if you never tried to understand why a single child developed encephalopathy following vaccination—you wouldn’t have the first clue as to what aspects of vaccination you could alter which could increase the relative risk of that adverse event (whether it be thimerosal, live virus, or ‘too many’). Could the susceptibility be a mitochondrial genetic haplogroup similar to Chloramphenicol toxicity—sure it could!  Why did a few Alzheimer’s patients die of fatal encephalitis following administration of the failed AN-1792 vaccine, but the majority had no ill effects (vaccine didn’t work though)? 

Definition:  Autism is a heterogeneous systemic disorder with primary neuropsychiatric manifestations due to complex genetic and gene-environmental interactions likely affecting synaptic plasticity early in childhood development.  This new theory of Autism is rapidly replacing the ‘old guard’ dictum that Autism is a genetically predetermined developmental brain disorder of synaptic formation/pruning that is set in motion prenatally.  By the ‘10 year rule of science,’ your time is about up! 

Until the biological basis of ASD subgroups are better understood, further epidemiological and genetic studies regarding “Autism” causation will be relatively meaningless.  We need good science to be able to address these complex issues which parallel nicely the emerging story of genetic and environmental influences in Parkinson’s disease.  Perhaps some Parkinson’s researchers want to take a crack at Autism?

Recommended SCIENCE reading for the evening:
 
Altered calcium homeostasis in autism-spectrum disorders: evidence from biochemical and genetic studies of the mitochondrial aspartate/glutamate carrier AGC1. Mol Psychiatry 2008 Jul 8.  (The discussion includes thimerosal as a potential toxin that could trigger further perturbations of calcium homeostasis leading to neuronal injury—and in a mainstream Nature publication no less)

Thank-you Dr. Novella and his band of skeptics for continuing the debate.

Dr. Jon Poling

Jon S. Poling MD PhD
Managing Partner, Athens Neurological Associates
Clinical Assistant Professor, Department of Neurology, Medical College of Georgia
Diplomate, American Association of Neuromuscular and Electrodiagnostic Medicine
ASN Certified in MRI and CT Neuroimaging

Comments

[Kelli Ann Davis]

Well, there you go! Girls rule (and don't even know it half the time) and Darla had it all figured out *without* even looking at "The Man Song" a.k.a; the-top-secret-spill-the-bean-5-bucks-a-pop-video-clip-that-I'm-trying-to-hawk.

BTW: Did'ya notice how the *man pact* lasted a whooping 1 minute once Darla walked onto the scene?

Moral of the story: Gals - 1, Guys - Zip.

(PS. I wonder who invented the cooties? ;-)

[Randy]

That'll learn me

Hopefully Craig and I helped to wash off some of the Savage comments this week. Little did I know that in doing so I ran the risk of being "outed" - guess there goes my membership in the "He Man Woman Haters Club"...

http://freemasonry.bcy.ca/fiction/other/our_gang.html

[Craig Willoughby]

Randy!! Traitor!! You're man-club license has been revoked.

:P

[Kelli Ann Davis]

Okay Randy, that by far is one of the funniest video clips I have *ever* watched in my life. I was rolling. *THIS* is a definite keeper.

So, you're telling me, in a nutshell, that we women could *make you* carry the purse if we really, really, I mean really wanted you to and that scares the you-know-what out of you?

Ahhhh....the feel of POWER! I wish I could bottle it and sell it. But since I can't do that, I'll just sell women this video clip instead.

So let the record show that RANDY spilled the beans.

5 bucks. Do I hear 5 bucks?

[Randy]

unfortunately i think the ultra-super-secret-man-code thing has been leaked...

http://www.toilette-humor.com/the-man-song.html

[Ilena Rosenthal]

It is not just coincidental that Novella, a part of the Quackwatch / Healthfraud team, made this very telling misstatement about cell phone dangers.

Cell phones, breast implants, vaccinations, genetically modified foods, second hand smoke, and amalgams are just a sampling of the issues that the respective industries merge their PR monies to pay junkscience.com and the so called "American Council of Science & Health" and various quacky frontgroups related to them.

They profit by keeping the facts covered up.

As a Breast Implant Awareness Activist, for 13 years, I have watched the identical tactics of these industries deny the dangers of their products, and Quackwatch and ACSH.org and junkscience.com used as their mouths for hire.

Their well funded game is to claim to have 'debunked' the dangers ... when in fact, the opposite is true. They are anti-science and fake "skeptics" ... having closed minds and opinions about ongoing medical concerns.

In my opinion, they are the current day equivalent of George Orwell's "Ministry of Truth" ... with up meaning down, black meaning white, and war meaning peace.

Perhaps Novella would be so kind as to admit how much he is being compensated and by whom to spend vast amounts of time and energy to give industry viewpoints on cell phones and vaccinations.

As silly as the name they gave themselves sounds, Stephen Barrett, David "Orac does not KNow" Gorski, and their "snake-oil vigilantes" are centers of disinformation and industry propaganda on Wikipedia, blogs, Usenet and their Healthfraud List.
www.BreastImplantAwareness.org/snake-oil.htm
(reproduction of list)

I am very grateful to see so many intelligent, organized, educated people standing up for the truth here.

With love & respect from Ilena
Victor, Barrett Vs Rosenthal
http://www.BreastImplantAwareness.org/BarrettVsRosenthal.htm

[Craig Willoughby]

Kelli.....we can't tell you. It's an ultra-super-secret-man-code thing. The guys know what I'm talking about (gives the fellas a nod and the super secret handshake).

Actually, it's because holding a purse implies several things. It detracts from his guyness, and guys carrying a purse implies to other guys that the one holding the purse is either whipped (for lack of a better word), or he's married to the purse owner. Both take away from his guyness, so it is an embarassment.

(You all know that this is all tongue-in-cheek, right?)

Hope that clears it up :P

[Rachel Ford]

I wonder if Steven Novella has read the transcripts from the Autism Omnibus proceedeings, specifically the transcript from 5/29/08.

Re: the issue of thimerosal/mercury dose and effect--

Expert witness Dr. Richard Deth said (in response to a government expert who stated that there is plenty of glutathione in the body to sweep away the mercury in the vaccines):

"The issue about how much glutathione is in the body vs. the amount of mercury in thimerosal is an issue of stoichiometry. Thimerosal and mercury are not interacting stoichiometrically one for one with glutathione. The ability of mercury to remain in the body and to enter the brain has been verified and shows that the vast amount of glutathione is not able to overwhelm this mercury; it’s there, and it causes effects. Dr. Jones seemed to develop an argument that because there is so much more glutathione, it would swamp out the thimerosal or mercury. But the number of proteins that eventually binds the mercury to the brain -- those targets exist in small quantities. The more valid question that Dr. Jones didn’t raise is what is the proportion of those protein targets for mercury in the body to the mercury in thimerosal? Is there enough mercury to saturate the body’s targets?
Q: Do the Charleston and Burbacher adult monkey studies show that the monkey brains have glutathione in them?
A: Surely they did. All cells have glutathione in them.
Q: And we know that the mercury was able to provoke neuroinflammation in those monkey brains?
A: Yes. The provocation of the inflammatory response is not because there’s so much mercury that it depletes the glutathione one for one; that’s not it. It’s because those critical regulatory mechanisms are built upon sulfur and thiols binding the mercury, and it’s their interaction that is causing the inflammation."

As Kent Heckinlively points out "The real issue is wheter the relatively small amount of protein targets for mercury in the body become overwhelmed by the mercury which remains".

There is also related research by Dr. Mandy Hornig of Columbia University on glutathione levels and thimerosal toxicity which just recently was replicated in Lima, Peru (Lorent, et al).

[Kelli Ann Davis]

“Craig - your wife must never talk to my wife.”

Ok. I mean it now. I want to KNOW why guys refuse to hold a purse!

Here’s a recent true story I’m gonna share (unless it gets deleted before it gets posted – hint 1) and when it happened I KNEW that refusing to *hold a purse* HAD to be a “universal guy thingy” but I still have no idea WHY.

A few months ago, I went to the airport to pick up a really *smart* guy (hint 2) who flew in to DC to help me with a meeting (hint 3) for the Subcommittee we’ve been working with.

So, he comes through the gate and I greet him and then realize I need to use the restroom and I’m balancing my diet drink in one hand, with my phone and purse in the other hand and I’m struggling and so I ask him, “Here, can you hold my purse for a second while I put my phone away and go into the bathroom?”

Well, you would have thought I had just asked him to hold a radioactive object (which by the way he’d have no problem understanding or explaining – hint 4) and so rather than just come out and say, “There is no way in h-e-double toothpicks I’m holding your purse” he steers me to a trash can with a lid on it so I can put my purse on top of it while I use the restroom!

Now, guys – what is UP with THAT? Like I really want my purse on top of a public trash can!!

So to all the guys (and especially Mr. “Scary Smart” guy – hint 5): Would one of you PLEASE give us gals a logical explanation on the whole purse thingy!!!????

Signed,

The-woman-who-dedorized-her-purse-as-soon-as-she-got-home-cuz-she-didn’t-like-the-thought-that-her-beloved-purse-was-delegated-to-a-public-trash-can.

[Randy]

Craig - your wife must never talk to my wife

:-)

[Carolyn]

Novella,

I think you should be looking more at children, with autism,instead of rats in a cages. It is a rediculous statement by saying that the rise in autism is caused by better diagnosis. Do you mind telling that "theory" to the educational systems across America? They are breaking at the seams by the influx of children with learning disabilities. Why do you think this has occured? Perhaps it is because each child is an individual and handles the toxins, live viruses and pollutants, that are added in the vaccine schedule, differently. Each child comes with a set of genetic vulnerabilites that makes them susceptable to toxic insults.
Also, What are you telling parents that are chelating their children and finding that they are getting better? These children are pouring out Lead, Aluminum, Tin, mercury etc...and they are getting better!! MORE and MORE kids are recovering. They are not going away...despite your colleages attempts to shut down doctors that actually KNOW how to treat the various maladies of autism. They are DOCTORS that have their own CHILDREN affected by this DISEASE. They hold the answers to our prayers. They are the heroes that are going to change this disaster from insideous to exhaulted.

You may want to inform your co-horts (insurance companies included)that looking at designed studies and not listening to parents will do you NO GOOD. You have insulted our intelligence and have wagered our children's health on your economic gains.

You are building your house on a deck of cards....and I predict a strong breeze coming your way.

[Craig Willoughby]

Jeane and Kelli,
You guys gave me a full-on belly laugh with the man-love reference. Thanks for that :)

And Kelli? My wife seems to have read your comment. Every time I walk in the house, now, she hands me her purse ;)

[Craig Willoughby]

Josh, I was going to post something about the Cell Phone story too. Isn't it funny how for years, closed minded morons like the skeptics club (which includes Orac, AutismNewsBeat aka. HerladBlog aka. MidwestDad aka. Ken Reibel and Dr. Novella here) all state that the cell phone/cancer story was a myth, that it couldn't possibly be true, and all of these studies that showed a link were complete fabrications and ridiculous claims.

Sound familiar?

[doodle]

"Infants, it turns out, excrete mercury better than adults, and evidence shows that the dose of mercury from thimerosal would not build up between vaccinations."

Does this Novella character really expect anyone here to believe this when we all know about Burbacher's work? What he is attempting to do is talk down to those of us who know the difference between having mercury leave the bloodstream (to go the brain maybe?) and mercury leaving the kidneys.

"There is sufficient safety data with vaccines to conclude that whatever dose children have received did not cause detectable toxicity"

Jugding by this bit of "knowledge", Dr. Novella did not even pay attention to any of Dr. Polings points about susceptible subsets.

So really, who cares about his opinion? He does not even try to care about an honest scientific point from Dr. Poling, so what is the use in arguing with him.

[Steven Novella]

Tim

Thanks for the thoughtful response. Regarding the claim that other mercury sources are replacing the removed thimerosal and concealing any effect of its removal - this is highly implausible that other sources would have precisely replaced thimerosal so that there was no detectable change in autism rates. There is also no evidence for this - it is a classic post-hoc rationalization, implausible, and without evidence. Also, there is at least one study showing no correlation with maternal vaccines, and most children either do not get the flu vaccine or get vaccine without thimerosal. Even if you assumed that every child received a flu vaccine with thimerosal (which is not true) the dose of thimerosal would still be much less than it was 10 years ago.

Your comments about dose are all true, and saying that toxicity is dose dependent does not deny other factors, and in fact incorporates other factors, like timing, physiology, and body weight.

Ethyl mercury (the form found in thimerosal) is less toxic and more easily removed than methyl mercury.

Infants, it turns out, excrete mercury better than adults, and evidence shows that the dose of mercury from thimerosal would not build up between vaccinations.

A survey of pediatrician offices showed that by 2002 less than 2% of vaccines in their offices contained thimerosal.

Regarding autism rates - I have been hearing that from Kirby and others for several years - that preliminary analysis of data shows that the rate is dropping. But then when all the data was in and published the rate was rising without the slightest change. If you are going to claim that rates are dropping you need to cite a published reference otherwise I have no idea if the data is reliable and properly analyzed.

Finally - if diagnosis rates of autism are due to expanded definition (a factor which has now already had its effect) and expanded surveillance - then autism rates should level off at their true rates. Because the true rates are not rising. So we fully expect rates to level off, but they should not drop, and they certainly should not drop to what they were pre 1990 - which is what Kirby and others predicted.

[Josh Day]

Very interesting thing appeared on CNN's website yesterday. It was on their front page last evening but it appears not to be anymore.

"Cancer Expert Warns Employees on Cell Phones:

http://www.cnn.com/2008/HEALTH/conditions/07/23/cancer.cell.phones.ap/index.html?iref=newssearch

CNN:

---
The head of a prominent cancer research institute issued an unprecedented warning to his faculty and staff Wednesday: Limit cell phone use because of the possible risk of cancer.

The warning from Dr. Ronald B. Herberman, director of the University of Pittsburgh Cancer Institute, is contrary to numerous studies that don't find a link between cancer and cell phone use, and a public lack of worry by the U.S. Food and Drug Administration.

Herberman is basing his alarm on early unpublished data. He says it takes too long to get answers from science, and he believes that people should take action now, especially when it comes to children.

"Really at the heart of my concern is that we shouldn't wait for a definitive study to come out but err on the side of being safe rather than sorry later," Herberman said. (CNN.com, see link above)

---

Then we have this wonderful, all-too familiar gem:

Joe Farren, a spokesman for the CTIA-The Wireless Association, a trade group for the wireless industry, said the group believes there is a risk of misinforming the public if science isn't used as the ultimate guide on the issue.

"When you look at the overwhelming majority of studies that have been peer reviewed and published in scientific journals around the world, you'll find no relationship between wireless usage and adverse health affects," Farren said.

---

What's really interesting is to read the entire article and replace the word "cell phone" with "vaccines."

Leave science to the SCIENTISTS, people! And to their benevolent praetorian guard the SKEPTICS, the crusaders for Holy Logic! Can't you get that through your feeble skulls already? After all, who needs simple observational skills and plain old common sense when when we have these scientific powerhouses to do all of our thinking and investigations?

Oh, and pay no mind to the man behind the curtain over there... after all, where's your proof he's actually there? I see something, perhaps... but I can't with any authority on scientific merit claim it's a man hiding over there!

[Twyla]

Thank you so much, Dr. Poling, for this excellent letter. It is so tiresome to hear the same untruths repeated ad infinitum, and it’s wonderful that you as father and doctor speak out to correct these lies/errors.

Two excellent letters from doctors were posted on AoA on the same day – the other is Dr. Gordon’s letter to Orac, which he posted under JB’s 5/29/2008 AoA article about Orac, a.k.a. David Gorski.

For a little while, I naively believed that these guys (such as Orac, Novella, AutismNewsBeat, Ozmum, D’oC) would listen to reason and to new information. They profess to be so logical, skeptical, science-oriented. But it is clear that they are completely, immovably, arrogantly set in their opinions, for whatever reasons. I think the New England Skeptical Society should change their name to the New England Hostile, Close-Minded and Prejudiced Society. Has a nice ring to it.

Yet, we continue to argue with them, not in the hope of changing their minds, but to make sure our side of the story is out there for other readers to see. It’s tremendous when doctors such as Dr. Poling and Dr. Gordon find the time to add their knowledgeable voices to the online discussion – risking professional recriminations, and loss of sleep too! (Dr. Gordon said he stayed up until 5:00 a.m. to write his post!)

The following may seem irrelevant, but I found it amusing: My husband is reading a book on "the historic search for atoms and their stellar origins" called "The Magic Furnace". Page 103 tells the story of a scientist named Arthur Stanley Eddington, who in about 1925 hypothesized that the sun’s energy was created by the conversion of hydrogen atoms into helium. But, for this to occur the sun’s temperature would have to be ten billion degrees, while he calculated the sun’s temperature to be only forty million degrees. (Later, it turned out that because the force of gravity is so strong in the sun, this process could actually take place at a lower temperature.)

"Infuriatingly, the center of the sun was nowhere near hot enough to weld hydrogen into helium. Despite this setback, Eddington remained convinced that the conversion of hydrogen to helium was the only conceivable energy source of the sun. When other astronomers chided him for ignoring his own evidence that the sun was too cold, he responded: ‘We do not argue with the critic who urges that the stars are not hot enough for this process; we tell him to go and find a hotter place.’ In other words, go to hell!"

There you have it – early 20th century bloggers! An age-old question – argue with them or just tell them to go to... ? Well, when their side gets so much publicity, and casts so many aspersions, and threatens to prevent development of science which could help thousands if not millions, I guess we have to keep arguing!

Getting back to the present topic of Dr. Novella... Regarding whether we are "in the midst of a true autism epidemic" – whether "true autism rates are increasing rapidly" – Dr. Novella says, "The evidence, however, supports the conclusion that the apparent increase is due largely to an expanded diagnosis and increased surveillance." This in itself shows him to be an idiot wearing blinders. Then he states that autism rates have not decreased so this proves that thimerosal isn’t a contributing factor – suddenly those autism diagnosis rates are reliable data. This is "Science-Based Medicine"? How can these guys be so proud of their rationality?

[Twyla]

Steven Novella said, "All medical interventions are about risk vs benefit - not absolute proof."

Yeah! That's just what we’ve been saying! Weigh both the risks and benefits of vaccines! Unfortunately, so many of the risks of vaccines have been largely ignored.

Parents say, "My baby received a bunch of vaccines and then became very ill and autistic" and they are told, "That’s just a coincidence! There's no connection, no causation! It’s the 'post hoc ergo propter hoc' fallacy!" and the vaccine injuries are not even studied. The parents are expected to present "absolute proof" of vaccine injury before these issues will even be studied.

But, as you said, it's not about absolute proof. Err on the side of safety! Flu shots should be packaged individually to avoid using the preservative thimerosal, even if they don't believe that we have presented absolute proof that it is dangerous to inject minute quantities of the second most toxic substance on earth! A child should not be given a bunch of vaccines at the same time, even if they don't yet have absolute proof that multiple vaccines could injure this particular child. The Gardasil vaccine should be recalled, even if we don’t yet have absolute proof that the deaths and paralysis and fainting and severe rash are caused by the vaccine.

And if you weigh the risks and benefits of the Hepatitis B vaccine, for the vast majority of babies the benefit is zero, so even a very small risk would tip the scales.

Wow, Dr. Novella, you accidentally argued for our side!

[Jim Witte]

Rule number one of pediatrics though is “LISTEN TO THE MOM.”

What?? I thought that was rule number 1 of *DAN!* Not Pediatrics.. Rule number 1 of pediatrics sadly seems to be "listen to Paul Offitt", the Pharma-biased NEJM et al., and IGNORE the moms.

Ignore the kids that have recovered too ("what do you mean 'recovered'?? They never had autism to begin with!").

Ignore the *findings* of measles virus in autistic kids made by Wakefield et al., which have never been challenged, even if his MMR-autism association has - and have even been replicated by others.

Ignore the success in of chelation in too many kids to ignore by continuing to call it "controversial" and whispering in private "voodoo medicine" or the like. This is a convenient way to get off the hook for actually having to do *studies* on whether it works. Ignore the small problem that there is A LOT OF HEAVY METALS coming out of these kids, and the even smaller question of "where did it come from???"

Ignore kids who have recovered brain function with HBOT, and say "what can it do - it's just air, after all?" Ignore the immunological findings (there are many), the skewed Th1/Th2 ratios (there must be data on immune cytokines SOMEWHERE), and the persistent connection to vaccines that just won't go away.

Yes, this is the way you do medical science at the dawn of the twenty-first century. Ignore the moms, ignore the patients... As the old proverb goes, we truly are cursed to live in interesting times.

[Cathy]

Risk vs Benefit of a newborn receiving a HepB vaccine with 24 hours of meeting this new world in Essex County, MA? Hmmm...Chances of that child coming in contact with HepB (if mother has tested neg) are slim to nil. Benefit of vaccine - small. Risk of newborn given a vaccination (not to mention loaded with or just a trace of toxins) without knowing the health of that child (because it was born only 24 hours ago)- medium to high.