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Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental.

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Presentation on theme: "Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental."— Presentation transcript:

1 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

2 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

3 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 Stickler GB, Simmons PS., Clin Pediatr 1995

4 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social 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 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 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social 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 GAO-05-458. 2005

6 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social 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)

7 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 Still growing and developing Absorption, metabolism, & elimination different Blood-brain barrier still forming in young infants Children differ physiologically:

8 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit 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 Increased Exposure from Inhalation and Dermal Absorption Miller M et al., Intl J Tox 2002

9 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Mean Water Intake Miller M et al., Intl J.Tox 2002

10 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 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 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

12 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

13 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

14 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 Wagner SL, Orwick DL., Pediatrics 1994

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

16 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Anticipatory Guidance Card

17 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 3 rd 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 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit 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 Pesticides and Children Zahm SH, Ward MH., EHP 1998

19 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social 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) Nishioka MG et al. EHP 2001

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

21 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Pesticide Report Card Environmental Working Group www.ewg.org Advice for Buying Organic

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

23 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Environmental History A ctivities – school, daycare, after school, sports, grandparents, church, etc. C ommunity – industry, agriculture, dump site, water pollution, water source H ousehold – dwelling, age, condition, heating sources, pesticides use, SHS H obbies – arts, crafts, fishing O ccupation – known exposures, fumes, dusts, vapors, Material Safety Data Sheets O ral behaviors – pica/mouthing

24 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 Kwon E. et al EHP 2004

25 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Advice for Patients & Providers Topic Health Effects Summary Sources and Prevention Strategies Routes of Exposure Arsenic

26 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 3 rd trimester and while breastfeeding Relationship to development, testing, treatment?

27 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

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

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

30 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? 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

31 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 Oken E et al., EHP 2005

32 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social 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. Hipkins KL, Materna BL, Payne SF, Kirsch LC., Clin Pediatri 2004

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

34 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit KEY CONCEPTS

35 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

36 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

37 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

38 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)

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

40 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social 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 CAL EPA 2005

41 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Smoking Hazards Addressed at Various Life Stages

42 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 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 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

44 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

45 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


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