Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for...

Pediatric Environmental Health Toolkit 2006

Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

The Pediatric Environmental Health Toolkit

Training Program for Health Care Providers

2006/2007



What We Will Cover

• Background on pediatricians’ current practices related to environmental health

• The unique vulnerabilities of children

• The development of the Pediatric Toolkit

• Case studies on environmental exposures

• How to use the Toolkit to address these issues



Parental Concern vs. Pediatrician Advice

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pediatrician advisesoftenparents worry "a lot"

Stickler GB, Simmons PS., Clin Pediatr 1995



The Environmental History in Pediatric Practice: A Study of Pediatricians’Attitudes, Beliefs, and Practices

• Fewer than 20% report training in environmental history taking.

• Strongly believe in importance of environmental exposures to children’s health. (53.5% had patient seriously affected)

• Lack confidence in environmental history-taking, and in discussing environmental exposures with patients.

Preferred resources: AAP patient education materials, newsletters

Kilpatrick N et al., EHP 2002



The Chemical Environment

• > 82,000 synthetic chemicals on EPA inventory of chemicals manufactured in U.S. today

• Most first synthesized in the past 50 years

• ~ 700 new chemicals introduced each year

• Few chemicals tested for basic toxicity

GAO-05-458. 2005



Chemicals Covered in Case Examples

Metals including Arsenic, Mercury and Lead

Pesticides

Persistent Organic Pollutants (POPs) (Example – PCBs)

Second Hand Smoke (SHS)



Unique Susceptibilities of Children

• Exploratory behavior• Crawling• Hand to mouth activity• Restricted diet• Teens – work, hobbies,

high risk behaviors

• Still growing and developing• Absorption, metabolism, & elimination different• Blood-brain barrier still forming in young infants

Children differ physiologically:



Increased metabolic rate

Higher minute ventilation

– Newborn 400 ml/min/kg

– Adult 150 ml/min/kg

Roughly double the surface

area to body wt.

– Increased absorption

from dermal route

.

B rea th ing ra te s ca lcu la ted fro m inha la t io n ra te s (m 3 /k g -d ay) and bo d y w e ig h ts rep o r ted in L ayto n (1 9 9 3 ); o r ig ina l d a ta fro m N F C S (1 9 7 7 -7 8 ) .

B re a th in g R a te s b y Ag e G ro u p

0

1 0 0

2 0 0

3 0 0

4 0 0

5 0 0

6 0 0

7 0 0

A g e G ro u p (y e a rs )

L/kg-d

ay

Increased Exposure from Inhalation and Dermal Absorption

Miller M et al., Intl J Tox 2002



Mean Water Intake

020406080

100120140160180200

gm/kg/d

<.5 .5-.9 1 to 3 4 to 6 7 to14

15 to19

20-44 45+

age in years

total waterintake ingm/kg/d

Miller M et al., Intl J.Tox 2002



The Pediatric Environmental Health Toolkit

• Developed to enable pediatric and family care providers to routinely include, in well-child visits,

information on preventing toxic exposures.

• The “Toolkit” includes visually exciting and creative materials that have been designed for easy use by practitioners.



Toolkit Development in Brief

• Demand for concise materials – Green Book “Cliff Notes”

• Developed by PSR, local American Academy of Pediatrics (AAP) chapters (Northern CA and MA), University of California San Francisco Pediatric Environmental Health Specialty Unity (UCSF PEHSU)

• Pilot tested in CA and MA

• Training Programs in 5 States funded by the EPA

• Endorsed by the AAP



Toolkit Provider Materials



Toolkit Patient Materials



Case 1 – Transient Hypertonia in an Infant

7lbs. 14 oz. term female, jaundice peak bili 12.6 Nl. PE at 12 weeks except lower extremity

hypertonicity Pediatric consult at 16 weeks - upper and lower

extremity hypertonicity, ankle clonus with Dx of cerebral palsy

Physical therapy begun No environmental hx was taken

Wagner SL, Orwick DL., Pediatrics 1994



Diazinon 1% sprayed by unlicensed pesticide applicator

Levels still high six months after spraying

Serum cholinesterase normal Urine metabolites high,

similar to post-shift urine of applicators Six weeks after removal from house

muscle tone returned to normal

Case 1 continued

Transient Hypertonia in an Infant

Wagner SL, Orwick DL., Pediatrics 1994



Anticipatory Guidance Card



Urban Exposure to Pesticides During Pregnancy Ubiquitous

NYC women wore backpack air samplers for 48 hrs during 3rd trimester

266/314 report pest measures at home (90% for cockroach)

ALL testing positive for exposure to at least 4 pesticides

Cord blood levels = maternal

Chlorpyrifos associated with decrease BW and length

Whyatt et al. Envir. Health Persp. 2002



Associations noted with:• Leukemia • Non-Hodgkin’s lymphoma• Soft tissue sarcoma• Brain tumors

– Same tumors repeatedly found in adult studies.

Also associations with:• Neurodegenerative disorders – Parkinson's Disease• Birth defects• Neurodevelopmental disorders

Pesticides and Children

Zahm SH, Ward MH., EHP 1998



Indoor ResiduesAfter Outdoor Pesticide Application

Pre-Application - 1.94 mcg/d

Post-Application – 8.87 mcg/d

Two Weeks After Application

2,4-D pesticide tracked in by family dog and home owner (applicator)

Nishioka MG et al. EHP 2001



• 23 children monitored for metabolites before/after organic diet • Levels of urinary metabolites reduced to non-detectable for

chlorpyrifos and malathion• Again elevated on re-introduction of conventional diet

Organic Diet Reduces Exposure to Common Agricultural Pesticides

Lu C, Toepel K, Irish R, Fenske RA, Barr DB, Bravo R, EHP. 2006



Pesticide Report Card

Environmental Working Group www.ewg.org

Advice for Buying Organic



Case 3 - Family with Unexplained Symptoms

Family (all 8 members/2 children) develops recurring neurologic and medical illness over four years, worse in winterFatigue, rashes, seasonal alopeciaRecurrent sever respiratory infectionsDebilitating headaches, malaiseSevere recurrent nosebleedsBoth children have “grand mal” seizures and

hyperesthesiaFish and houseplants have died

Peters HA, Croft WA, Woolson EA, Darcey BA, Olson MA., JAMA 1984



Environmental History

Activities – school, daycare, after school, sports, grandparents, church, etc.

Community – industry, agriculture, dump site, water pollution, water source

Household – dwelling, age, condition, heating sources, pesticides use, SHS

Hobbies – arts, crafts, fishing

Occupation – known exposures, fumes, dusts, vapors, Material Safety Data Sheets

Oral behaviors – pica/mouthing



Case 3 – continued

Unexplained Symptoms• Family used recycled “old” wood in their stove

- Chromated Copper Arsenate (CCA) treated wood - Stove ashes with > 1,000 ppm arsenic

contaminated living area• CCA – commonly used wood preservative (decks,

playground equipment etc.) No longer produced for residential use.

• Arsenic – anti-metabolite, interferes with ATP cycle. Known human carcinogen

Kwon E. et al EHP 2004



Advice for Patients & Providers

Topic Health Effects Summary Sources and Prevention Strategies

Routes of Exposure

Arsenic



Case 4 - Patient Concerned About Fish Consumption

3½ y/o male with a diagnosis of developmental/behavioral disorder at age 3

Otherwise healthy except for eczema Normal birth Hx Exclusively breastfed for 3 months, then

transitioned to formula Mother ate 1- 2 tuna steaks per week during 3rd

trimester and while breastfeeding Relationship to development, testing, treatment?



Mercury: Health Effects Prenatal Exposure

Higher Dose

Mental retardation, seizures, disturbances of vision, hearing, motor control

Lower Dose

Impairments in attention, memory, and language

Delayed conduction on BAER



Tuna Mercury Concentrations*

Mean - 0.38 ug/g Maximum - 1.3 ug/g

Patient weight ~ 70 kg

Serving size (tuna steak) ~ 8 ozs (227 grams)

Dose Calculation (average)

0.38 ug/g x 227g x 1.5 servings / 70 kg wt. x 7 days = 0.26 ug/kg-day (high-end 0.9 ug/kg-day)

Both exceed EPA reference dose 0.1 ug/kg-day

*FDA data from 2004

Mercury Dose Calculation for Concerned Patient



• CDC data show approximately 5.7-8% of US women of childbearing age exceed EPA defined safe exposure limit

• Government agencies provide guidance on mercury in fish

• States provide guidance on freshwater fish consumption guidelines

Population Exposures are Significant – Government has Taken Action



How Much Fish is Safe?

•Do Not feed children swordfish, shark, mackerel (King), and tilefish.

•“Chunk light” vs “solid white” albacore (limit amt based on weight)

•Serve a variety of fish and seafood - Haddock, pollock and shrimp are among the low fat, low mercury choices.

Enter your body weight in pounds:

Select the species of fish you eat:

Get your Results!

IATP Fish Calculator

www.iatp.org



Benefits of Maternal Fish Consumption Lessened by Mercury Exposure

Fish is a good food source:• Source of protein, iron, vitamin E, selenium, and long

chain n-3 polyunsaturated fatty acids• Higher fish consumption associated with improved infant

cognition

• However...Higher mercury (even very low dose) associated with reduced cognition

Suggests eating fish with less mercury

Oken E et al., EHP 2005



Case 5 - Occupational/Take Home Exposures A day laborer goes to the ER for a work related injury. He is working on demolishing a firing range so a lead

level is obtained and is 74 mcg/dl after 3 days on this job. Four other workers tested between 57 and 98

(all worked less than 2 ½ weeks). What should be done? None had previously worked with

lead.

Hipkins KL, Materna BL, Payne SF, Kirsch LC.,Clin Pediatri 2004



Case 5 - continued

Occupational/Take Home Exposures

9 children of three workers tested between 13 and 34 mcg/dl. (highest 18 month old)

Wife of one with symptoms and Pb level of 36 mcg/dl.

Workers may bring home hazards on clothing, shoes, and body.

In 2001-2002 year, 22% of California childhood lead poisoning cases had potential contribution from occupational sources.



KEY CONCEPTS



Case 6 – Exposure but no Symptoms

Father concerned that for past seven months oily residue found on driveway/car

Children play in that area Finally determined coming from power transformer

just off property Is there potential danger?

• Power company contacted and said nothing to worry about

Know Your Resources: ATSDR, EPA regional office, PEHSU, state offices, AOEC



PCB Exposure In Utero

Health Effects:

•Decrease in full scale and verbal IQ at 11 years old

•Decrease in word and reading comprehension

•Decrease in memory and attention



Breastfeeding is Best for Baby



Second Hand Smoke (SHS)



Developmental Effects –Fetal Growth: LBW and decreased birthweight –Sudden Infant Death Syndrome

Respiratory Effects –Acute lower RTIs in children –Asthma induction and exacerbation-children/adults–Chronic respiratory symptoms in children –Eye and nasal irritation in adults –Middle ear infections in children

Carcinogenic Effects –Lung Cancer, Nasal Sinus Cancer –Breast Cancer

Cardiovascular Effects –Heart disease mortality and morbidity

Effects Causally Associated w/ SHS Exposure

CAL EPA 2005



SHS & Breast Cancer - Premenopausal Women

• 14 Studies Reviewed - 13 found an Increase in Risk (7 statistically significant)

• 70% Increase in Breast Cancer Risk

• Windows of susceptibility during rapid proliferation

CAL EPA 2005



Smoking Hazards Addressed at Various Life Stages



Summary

• The body of scientific evidence continues to build regarding the impact of environmental toxicants on children’s health

• A precautionary approach that emphasizes prevention is good patient and public health

• Guidance on preventing exposures to children and families can be incorporated by pediatric providers into well child visits using the Pediatric Environmental Health Toolkit

• Society needs to work on “upstream” prevention issues beyond the clinical setting



Acknowledgements

Primary Author:Mark Miller MD MPH

Contributing Authors/Reviewers:Michelle Gottlieb MEM, Guenter Hofstadler MD, Brian Linde MD, Siobhan McNally MD,Marybeth Palmigiano MPH, Kathy Shea MD,Gina Solomon MD MPH, Maria Valenti,David Wallinga MD MPA



Planning and Development Physician Group California

Lisa Asta MD FAAP - Chair, Department of Pediatrics, John Muir Medical Center

Guenter Hofstadler MD MPH FAAP - Pediatrician, Contra Costa Regional Medical Center

Brian Linde MD FAAP - Pediatric Hospital Based Specialist, Kaiser Permanente, Oakland, California

Mark Miller MD MPH FAAP - Pediatrician and Director, UCSF Pediatric Environmental Health Specialty Unit

Massachusetts

Siobhan McNally MD FAAP - Berkshire Medical Center and the University of Massachusetts Medical School

Minnesota

David Wallinga MD MPA - Senior Scientist and Antibiotic Resistance Project Director, Institute for Agriculture and Trade Policy



For More Information

Greater Boston Physicians for Social Responsibility

617- 497-7440 - www.igc.org/psr

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