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The Pediatric Environmental

Health Toolkit
Training Program for
Health Care Providers
2006/2007

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Responsibility, UCSF Pediatric Environmental Health Specialty Unit
Parental Concern vs. Pediatrician Advice

80
70
60
50
40
30 pediatrician advises
20 often
10 parents worry "a lot"
0
television

env. toxins
immunization

eating right
ear infections

car accidents

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Stickler GB, Simmons PS., Clin Pediatr 1995 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Kilpatrick N et al., EHP 2002 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
GAO-05-458. 2005 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
Chemicals Covered in Case Examples

Metals including Arsenic, Mercury and


Lead

Pesticides

Persistent Organic Pollutants (POPs)


(Example – PCBs)

Second Hand Smoke (SHS)

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Responsibility, UCSF Pediatric Environmental Health Specialty Unit
Increased Exposure from
Inhalation and Dermal Absorption
.

Increased metabolic rate Breath in g R ates b y Ag e G ro u p


Higher minute ventilation 700
600
– Newborn 400 ml/min/kg 500
400
– Adult 150 ml/min/kg

L/kg-day
300
200
Roughly double the surface 100
0

area to body wt.


– Increased absorption Ag e G ro u p (ye a rs)

 Breathing rates calculated fro m inhalatio n rates (m 3 /kg-day) and bo dy w eights


from dermal route reported in Layto n (1993); original data fro m N FCS (1977 -78).

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Miller M et al., Intl J Tox 2002 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
Mean Water Intake

200
180
160
140
120
gm/kg/d 100
80 total water
60 intake in
40 gm/kg/d
20
0
<.5 .5-.9 1 to 3 4 to 6 7 to 15 to 20-44 45+
14 19
age in years

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Miller M et al., Intl J.Tox 2002 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
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.

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Wagner SL, Orwick DL., Pediatrics 1994 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
Case 1 continued
Transient 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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Wagner SL, Orwick DL., Pediatrics 1994 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
Anticipatory Guidance Card

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Whyatt et al. Envir. Health Persp. 2002 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
Pesticides and Children

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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Zahm SH, Ward MH., EHP 1998 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
Indoor Residues
After 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)

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Nishioka MG et al. EHP 2001 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
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

Pediatric Environmental Health Toolkit 2006


Lu C, Toepel K, Irish R, Fenske RA, Barr DB, Greater Boston and San Francisco Bay Area Physicians for Social
Bravo R, EHP. 2006 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
Advice for Buying Organic

Pesticide Report Card

Pediatric Environmental Health Toolkit 2006


Environmental Working Group Greater Boston and San Francisco Bay Area Physicians for Social
www.ewg.org Responsibility, UCSF Pediatric Environmental Health Specialty Unit
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

Pediatric Environmental Health Toolkit 2006


Peters HA, Croft WA, Woolson EA, Darcey BA, Greater Boston and San Francisco Bay Area Physicians for Social
Olson MA., JAMA 1984 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
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
Pediatric Environmental Health Toolkit 2006
Greater Boston and San Francisco Bay Area Physicians for Social
Responsibility, UCSF Pediatric Environmental Health Specialty Unit
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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Kwon E. et al EHP 2004 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
Advice for Patients & Providers

Topic Health Effects Summary Sources and Prevention Strategies


Routes of Exposure

Arsenic

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Responsibility, UCSF Pediatric Environmental Health Specialty Unit
How Much Fish is Safe?

IATP Fish Calculator

•Do Not feed children swordfish,


Enter your body
weight in pounds: shark, mackerel (King), and tilefish.
•“Chunk light” vs “solid white”
Select the species of
fish you eat: albacore (limit amt based on weight)
•Serve a variety of fish and seafood -
Get your Results! Haddock, pollock and shrimp are
among the low fat, low mercury
choices.
www.iatp.org

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Oken E et al., EHP 2005 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
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.

Pediatric Environmental Health Toolkit 2006


Hipkins KL, Materna BL, Payne SF, Kirsch LC., Greater Boston and San Francisco Bay Area Physicians for Social
Clin Pediatri 2004 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
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.

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Responsibility, UCSF Pediatric Environmental Health Specialty Unit
Second Hand Smoke (SHS)

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Responsibility, UCSF Pediatric Environmental Health Specialty Unit
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
Pediatric Environmental Health Toolkit 2006
Greater Boston and San Francisco Bay Area Physicians for Social
CAL EPA 2005 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
CAL EPA 2005 Responsibility, UCSF Pediatric Environmental Health Specialty Unit
Smoking Hazards
Addressed at Various Life Stages

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


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

Pediatric Environmental Health Toolkit 2006


Greater Boston and San Francisco Bay Area Physicians for Social
Responsibility, UCSF Pediatric Environmental Health Specialty Unit
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
Pediatric Environmental Health Toolkit 2006
Greater Boston and San Francisco Bay Area Physicians for Social
Responsibility, UCSF Pediatric Environmental Health Specialty Unit
For More Information

Greater Boston Physicians


for Social Responsibility

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

Pediatric Environmental Health Toolkit 2006


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

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