Pediatric Environmental Health Toolkit 2006

1
The Pediatric Environmental Health Toolkit
Training Program for Health Care
Providers2006/2007
2
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

3
Parental Concern vs. Pediatrician Advice
Stickler GB, Simmons PS., Clin Pediatr 1995
4
The Environmental History in Pediatric Practice
A Study of PediatriciansAttitudes, Beliefs, and
Practices

• Fewer than 20 report training in environmental
  history taking.
• Strongly believe in importance of environmental
  exposures to childrens 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
5
The Chemical Environment

• gt 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
6
Chemicals Covered in Case Examples
Metals including Arsenic, Mercury and
Lead Pesticides Persistent Organic Pollutants
(POPs) (Example PCBs) Second Hand Smoke (SHS)
7
Unique Susceptibilities of Children

• Exploratory behavior
• Crawling
• Hand to mouth activity
• Restricted diet
• Teens work, hobbies, high risk behaviors

Children differ physiologically

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

8
Increased Exposure from Inhalation
and Dermal Absorption

• 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

Miller M et al., Intl J Tox 2002
9
Mean Water Intake
Miller M et al., Intl J.Tox 2002
10
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.

11
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

12
Toolkit Provider Materials
13
Toolkit Patient Materials
14
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
15
Case 1 continuedTransient Hypertonia in an Infant

• 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

Wagner SL, Orwick DL., Pediatrics 1994
16
Anticipatory Guidance Card
17
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
18
Pesticides and Children

• Associations noted with
• Leukemia
• Non-Hodgkins 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

Zahm SH, Ward MH., EHP 1998
19
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
20
Organic Diet Reduces Exposure to Common
Agricultural Pesticides

• 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

Lu C, Toepel K, Irish R, Fenske RA, Barr DB,
Bravo R, EHP. 2006
21
Pesticide Report Card
Advice for Buying Organic
Environmental Working Group www.ewg.org
22
Case 3 - Family with Unexplained Symptoms

• Family (all 8 members/2 children) develops
  recurring neurologic and medical illness over
  four years, worse in winter
• Fatigue, rashes, seasonal alopecia
• Recurrent sever respiratory infections
• Debilitating headaches, malaise
• Severe recurrent nosebleeds
• Both children have grand mal seizures and
  hyperesthesia
• Fish and houseplants have died

Peters HA, Croft WA, Woolson EA, Darcey BA,
Olson MA., JAMA 1984
23
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

24
Case 3 continuedUnexplained Symptoms

• Family used recycled old wood in their stove
• Chromated Copper Arsenate (CCA) treated wood
• Stove ashes with gt 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
25
Advice for Patients Providers
Topic Health Effects
Summary Sources and
Prevention Strategies Routes of
Exposure
Arsenic
26
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?

27
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

28
Mercury Dose Calculation for Concerned Patient

• 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

29
Population Exposures are Significant Government
has Taken Action

• 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

30
How Much Fish is Safe?
IATP Fish Calculator

• 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!
www.iatp.org
31
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
32
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
33
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.

34
KEY CONCEPTS
35
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
36
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

37
Breastfeeding is Best for Baby
38
Second Hand Smoke (SHS)
39
Effects Causally Associated w/ SHS Exposure

• 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

CAL EPA 2005
40
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
41
Smoking Hazards Addressed at Various
Life Stages
42
Summary

• The body of scientific evidence continues to
  build regarding the impact of environmental
  toxicants on childrens 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

43
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

44
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
45
For More Information Greater Boston Physicians
for Social
Responsibility
617- 497-7440 - www.igc.org/psr