Out of Harm’s Way:
Preventing Toxic Threats to
Child Development
Oregon Physicians
for Social Responsibility
www.oregonpsr...
Introduction

Today’s Presentation
•Scope of the problem of neurodevelopmental
& learning disabilities.
•Human vulnerabili...
Introduction

Image: http://www.flickr.com/photos/tkneen/319265454/

Precautionary
Principle

“When an activity raises thr...
Introduction

Prevalence of
Learning and
Behavioral Disabilities
•Total: 17%, 12 million children
•Learning disabilities: ...
Introduction

Economic Implications
 $81.5 – $167 billion/yr - Neurodevelopmental deficits & related disorders.
 $9.2 bi...
AMA Resolution
In June, 2008, the American Medical Association
issued a resolution stating that there was a need for
toxic...
The Significance of Small Effects
Example: population of 260 million

mean 100

6.0 million
"gifted"

6.0 million
"mentall...
5 Point Decrease in Mean IQ
mean 95
57% INCREASE IN
"Mentally
Retarded”
Population

2.4 million
"gifted"

9.4 million
"men...
What causes developmental
syndromes?
Multiple factors interact in complex ways
during fetal development.

Internal factors...
Leonardo da Vinci

Measurable
Impact
The result can be any
one or combination
of the traits and
behaviors we identify
in d...
Embryonic Development &
Vulnerability of Vulnerability
Windows
Introduction

Children are More Vulnerable to
All Toxins
• Eat, breathe & drink more per pound
• Mouth breathers
• Immatur...
Introduction

Our Chemical Environment:
The State of Knowledge
• >81,000 chemicals, estimate
700 new chemicals/year.
• 62,...
Introduction

Lack of Testing for Developmental
Effects
Some Data
On Developmental
Toxicity

0.4%

33.1%

66.5%
No Data
On...
THE TOXIC ICEBERG
PROVEN HARM

PARTIALLY
PROVEN

NOT YET RECOGNIZED

FOREVER UNRECOGNIZED

Introduction
Synergistic Effects
• Adverse effects of toxins are
often synergistic
• Advisories based on analysis of a
single chemical ...
Introduction

Parental Concern vs.
Pediatrician Advice

ea

ri
nfe
i m c ti
mu on
niz s
a ti
tel on
ca evis
ra
i on
cci
ea...
Taking An Environmental
History
• Activities –

school, daycare, after
school, sports, grandparents, church, etc.
• Commun...
Lead
Lead

Lead (Pb): a Persistent Problem
• Nationally: 2.2% have BLL predictive of lower IQ.
• New data: BLL<10 may reduce IQ...
EXPOSURE – blood lead, ug/dl

DECLINING
lead
THRESHOLD OF HARM - LEAD
100

Reported
Harm (CDC)

10

?New
Level?

1

0.1
19...
Effects of Lead
on Cognitive and Behavioral
Traits LD
ADHD

hyperactivity
impulsivity
distractibility
diff. w instructs
co...
Health Effects
• Developmental effects:

•
•
•
•
•
•
•
•

– ADHD
– learning disabilities
– Lowered IQ

Chronic renal disea...
Lead

Sources
• Toys, plastic nipples and baby
bottles
• Old paint & water pipes
• Home renovation (in dust)
• Gasoline (s...
Advise Patients
• Regularly clean areas where children play;
• Clean/remove shoes outside;
• Limit use of toys, bottles & ...
Methyl mercury

Coal-fired power plant in Cheshire, Ohio from http://www.flickr.com/photos/dshea/2089737103/
Methylmercury

Methyl mercury (H3C-Hg+)
• Nationally: EPA estimates that 160 tons
released annually.
• In Oregon: 4,500 lb...
The Mercury Cycle

Mercury
Methyl mercury
Mercury

Toxic Effects of Methyl mercury
• Mental retardation and
developmental disabilities
• Learning imp...
Mercury
Basic Toxicology: Exposure
Concepts

• Persistence
PCBs, heavy metals, pesticides

• Bioaccumulation
Heavy metals, pestici...
Breastfeeding is Best for Baby
Mercury

Mercury Exposures
• 5-8% of women of reproductive age
exceed recommended Reference Dose
(RfD) of 0.1mcg/kg/day.
•...
Mercury
Mercury:
Declining Threshold of Harm
100

Level associated with
harmful effect
Regulatory standard
(maximum safe e...
Mercury

Benefits of Maternal Fish Consumption
Lessened by Mercury Exposure




Eat more fish with
less mercury
Oken E e...
Mercury

Advise Patients
• Recommend children <6yrs and women of
child-bearing age avoid fish high in mercury.
• Provide p...
Mercury

Guide to Healthy Fish

CHECK LOCAL AND STATE
FISH ADVISORIES at
www.healthoregon.org/fishadv

• AVOID: Mackerel-K...
Mercury

How Much Fish is Safe?
IATP Fish Calculator

Enter your body
weight in pounds:
Select the species of
fish you eat...
Pesticides
Pesticides

Pesticides: a Persistent Problem
• Definition: Physical, chemical or biological agent
intended to kill an unde...
Pesticides

Pesticides and Health
Associations noted with:

– Neurodegenerative disorders
• Parkinson's Disease

– Birth d...
Pesticides

Background Pesticide
Exposures Widespread
• Reported use: 98% of families, 80% during
pregnancy.
• In Humans: ...
Organophosphate
Pesticides

Pesticides

Occurrence and distribution of 11 types in surface &
ground water of the United St...
Pesticides

Anthropological Study of
Children Exposed to Pesticides

Children from villages
practicing organic agriculture...
Pesticides

Case: Transient Hypertonia in an
Infant
• 7lbs. 14 oz. term female, jaundice peak bili
12.6
• Normal physical ...
Pesticides

Transient Hypertonia in an Infant
• Diazinon 1% sprayed by
unlicensed pesticide applicator
• Levels still high...
Anticipatory Guidance Card

http://www.flickr.com/photos/andreasbalzer/433048027/

Pesticides
Pesticides

Urban Exposure to Pesticides
During Pregnancy Ubiquitous
• NYC women wore
backpack air samplers for
48 hrs dur...
Pesticides

Organic Diet Reduces Exposure to
Common Agricultural Pesticides

• 23 children monitored for metabolites befor...
Pesticides

Advise Patients
•
•
•
•
•

Regularly clean areas where children play;
Practice Integrated Pest Management (IPM...
Pesticides

Advice for Buying Organic:
Pesticide Guides

Institute for Agriculture and Trade Policy
Conclusions

Emerging Themes
• The more we learn about chemicals, the
lower we shift the toxic “thresholds”.
• Subtle effe...
Conclusions

Guiding Principles
•

Disabilities are widespread. Toxic exposures
are preventable contributors.

•

Apparent...
Conclusions

What Can You Do?
• Be aware of
environmental
toxins & possible
effects.
• Provide
education on
prevention and...
Acknowledgments
• Greater Boston
Physicians for Social
Responsibility
• Washington Physicians
for Social Responsibility
• ...
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  • Image is of toys (not necessarily containing lead) from: http://www.flickr.com/photos/justanuptowngirl/2249080112/
  • Transcript of "Out of Harm's Way: Preventing Toxic Threats to Child Development"

    1. 1. Out of Harm’s Way: Preventing Toxic Threats to Child Development Oregon Physicians for Social Responsibility www.oregonpsr.org
    2. 2. Introduction Today’s Presentation •Scope of the problem of neurodevelopmental & learning disabilities. •Human vulnerability to toxic chemicals, focusing on children. • Current chemical environment, focusing on mercury & pesticides in Oregon. • What you can do to help your patients minimize exposures.
    3. 3. Introduction Image: http://www.flickr.com/photos/tkneen/319265454/ Precautionary Principle “When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically.” Wingspread Conference, 1998
    4. 4. Introduction Prevalence of Learning and Behavioral Disabilities •Total: 17%, 12 million children •Learning disabilities: 5-10% •One in eight Oregon children use special education services •Autism: 0.3- 0.66%; 1 in 150 young children
    5. 5. Introduction Economic Implications  $81.5 – $167 billion/yr - Neurodevelopmental deficits & related disorders.  $9.2 billion/yr - Attributable to environmental pollutants.  Over $8000/yr – Special education costs for a child with autism.  $800 million/yr - OR special ed costs.
    6. 6. AMA Resolution In June, 2008, the American Medical Association issued a resolution stating that there was a need for toxics reform: • To implement new, federal regulation to test and update all chemicals in use today; • To restructure the 1976 Toxic Substances Control Act (TSCA) to effectively achieve these goals; • To adopt safer production and uses of all chemicals; • To encourage the training of medical students, physicians, and other health professionals about the human health effects of toxic chemical exposures with the help of the AMA.
    7. 7. The Significance of Small Effects Example: population of 260 million mean 100 6.0 million "gifted" 6.0 million "mentally retarded" 40 80 60 70 100 I.Q. 120 140 130 160
    8. 8. 5 Point Decrease in Mean IQ mean 95 57% INCREASE IN "Mentally Retarded” Population 2.4 million "gifted" 9.4 million "mentally retarded" 40 80 60 70 100 I.Q. 120 140 130 160
    9. 9. What causes developmental syndromes? Multiple factors interact in complex ways during fetal development. Internal factors • Genetic traits & susceptibility External factors • Exposure to toxins • Nutrition • Social environment
    10. 10. Leonardo da Vinci Measurable Impact The result can be any one or combination of the traits and behaviors we identify in developmental syndromes including learning disabilities, Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders (ASD) and others.
    11. 11. Embryonic Development & Vulnerability of Vulnerability Windows
    12. 12. Introduction Children are More Vulnerable to All Toxins • Eat, breathe & drink more per pound • Mouth breathers • Immature brain and blood-brain barrier • Gastrointestinal tract & skin have two times the surface area of adults • Outside more & closer to ground • Hand-to-mouth behaviors • Lower enzyme levels
    13. 13. Introduction Our Chemical Environment: The State of Knowledge • >81,000 chemicals, estimate 700 new chemicals/year. • 62,00 chemicals grandfathered in with no testing requirements. • >4 billion lbs per year, including 72 million lbs carcinogens. Problem: Data available for just a few chemicals. No data available for majority!
    14. 14. Introduction Lack of Testing for Developmental Effects Some Data On Developmental Toxicity 0.4% 33.1% 66.5% No Data On Developmental Toxicity Only 12 Tested for Neurodevelopmental Toxicity According to EPA Guidelines
    15. 15. THE TOXIC ICEBERG PROVEN HARM PARTIALLY PROVEN NOT YET RECOGNIZED FOREVER UNRECOGNIZED Introduction
    16. 16. Synergistic Effects • Adverse effects of toxins are often synergistic • Advisories based on analysis of a single chemical are unlikely to protect public health
    17. 17. Introduction Parental Concern vs. Pediatrician Advice ea ri nfe i m c ti mu on niz s a ti tel on ca evis ra i on cci ea dent tin s gr en ight v. to x ins 80 70 60 50 40 30 20 10 0 Stickler GB, Simmons PS., Clin Pediatr 1995 pediatrician advises often parents worry "a lot"
    18. 18. Taking An 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
    19. 19. Lead
    20. 20. Lead Lead (Pb): a Persistent Problem • Nationally: 2.2% have BLL predictive of lower IQ. • New data: BLL<10 may reduce IQ proportionally more than higher levels, affecting up to 16% children. • Oregon: 2% homes high risk & 1% tested kids<6yo have elevated BLL. • Multnomah County: 4% homes high risk. • Lead phase out: paint 70s; gas 80s; plumbing 1985. • Lack of OR regulation: 19/48 industries air & 5/18 water have permits – we know nothing about the rest.
    21. 21. EXPOSURE – blood lead, ug/dl DECLINING lead THRESHOLD OF HARM - LEAD 100 Reported Harm (CDC) 10 ?New Level? 1 0.1 1960 1970 1980 1990 YEAR REPORTED 2000
    22. 22. Effects of Lead on Cognitive and Behavioral Traits LD ADHD hyperactivity impulsivity distractibility diff. w instructs conduct problems executive function attention/vigilance social skills reading, math spelling pattern recognition word recognition OTHER fine motor visual motor aggressive antisocial off-task Lead
    23. 23. Health Effects • Developmental effects: • • • • • • • • – ADHD – learning disabilities – Lowered IQ Chronic renal disease, nephritis Dementia Atherosclerosis Peripheral neuropathy Behavioral changes Reduced sperm count and libido Miscarriages Hypertension Lead
    24. 24. Lead Sources • Toys, plastic nipples and baby bottles • Old paint & water pipes • Home renovation (in dust) • Gasoline (soil contamination) • Industrial/workplace emissions • Hobbies-lead solder • Bone release during pregnancy if calcium deficient • Breast milk • Costume jewelry & under-fired terra cotta • Folk remedies (greta, azarcon, rueda) • Vinyl and non-glossy mini-blinds http://www.flickr.com/photos/wayneandwax/119879781 /
    25. 25. Advise Patients • Regularly clean areas where children play; • Clean/remove shoes outside; • Limit use of toys, bottles & pacifiers which may contain lead in paint or plastics, wash often; • Test homes built before 1978, esp. if being remodeled; – Clean up paint chips, keep paint in good condition; • Test drinking water & replace Pb solder-if unable, use COLD water; • Testing for all immigrants, Medicaid patients & low SES; Call the Multnomah Co Lead Line 503-988-4000: free tap water testing, BLL clinics, safe home remodeling, risk assessment help Lead
    26. 26. Methyl mercury Coal-fired power plant in Cheshire, Ohio from http://www.flickr.com/photos/dshea/2089737103/
    27. 27. Methylmercury Methyl mercury (H3C-Hg+) • Nationally: EPA estimates that 160 tons released annually. • In Oregon: 4,500 lbs released from human sources annually. • Lack of OR regulation: 10 facilities report Hg release, but Oregon does not require emissions monitoring. • Poisonings: Minamata 1950s & Iraq 1971.
    28. 28. The Mercury Cycle Mercury
    29. 29. Methyl mercury Mercury Toxic Effects of Methyl mercury • Mental retardation and developmental disabilities • Learning impairments • Behaviors associated with • • • • • – Autism Spectrum Disorder (ASD) – Attention Deficit Hyperactivity Disorder (ADHD) Hearing loss, balance problems Visual impairment Peripheral neuropathy Seizure disorder Abnormal reflexes & muscle tone http://www.flickr.com/photos/nirak/206930221/
    30. 30. Mercury
    31. 31. Basic Toxicology: Exposure Concepts • Persistence PCBs, heavy metals, pesticides • Bioaccumulation Heavy metals, pesticides • Transient exposures Ongoing and prenatal exposures
    32. 32. Breastfeeding is Best for Baby
    33. 33. Mercury Mercury Exposures • 5-8% of women of reproductive age exceed recommended Reference Dose (RfD) of 0.1mcg/kg/day. • 50% of women who eat fish exceed RfD on any given day. • Higher risk: Children (estimated 300,000 per year) of women with higher mercury intake; Subsistence fishers, immigrants, Native Americans. • Fish Advisories: in 2004, 44 states had over 2000 warnings; OR lists 16 water bodies with mercury advisories.
    34. 34. Mercury Mercury: Declining Threshold of Harm 100 Level associated with harmful effect Regulatory standard (maximum safe exposure or high contamination) end exposure from allowed fish (micrograms/kg/day Hg) DAILY INTAKE 10 1 FDA WHO ATSDR 0.1 EPA 0.01 1970 1980 YEAR 1990 2000
    35. 35. Mercury Benefits of Maternal Fish Consumption Lessened by Mercury Exposure   Eat more fish with less mercury Oken E et al., EHP 2005  Fish is a good food source: - protein, iron, vitamin E, selenium, and long chain n3 polyunsaturated fatty acids Higher fish consumption associated with improved infant cognition However...Higher mercury exposure (even very low dose) associated with reduced cognition
    36. 36. Mercury Advise Patients • Recommend children <6yrs and women of child-bearing age avoid fish high in mercury. • Provide pregnant women copies of Healthy Fish, Healthy Families (PSR) and An Expectant Mother’s Guide to Eating Fish in Oregon (DHS) • Have car checked for mercury switches at participating auto shop (free replacement with nonHg switch). • Use digital thermometers & thermostats. • Recycle old mercury thermometers, thermostats & compact fluorescent bulbs or tubes: 1-800RECYCLE
    37. 37. Mercury Guide to Healthy Fish CHECK LOCAL AND STATE FISH ADVISORIES at www.healthoregon.org/fishadv • AVOID: Mackerel-King, Shark, Swordfish, Tilefish; In OR, also Bass (large & smallmouth), Brown Trout. • <2 servings/month (Hg &/or PCBs): Salmon, Sardines, Herring, Bluefish. • <1 serving/wk: Lobster, Tuna, Mackerel-Spanish, Marlin, Orange Roughy, Grouper; In OR, also Walleye, Carp, Catfish, Sturgeon.
    38. 38. Mercury How Much Fish is Safe? IATP Fish Calculator Enter your body weight in pounds: Select the species of fish you eat: Get your Results! www.iatp.org www.ewg.org •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.
    39. 39. Pesticides
    40. 40. Pesticides Pesticides: a Persistent Problem • Definition: Physical, chemical or biological agent intended to kill an undesirable plant or animal pest. • Major classes: insecticides, fungicides, herbicides. • Market: in 1997, USA $11.9 billion & World $37 billion. • History: new to humans & environment since 1940s; over 800 licensed as “active” ingredients by EPA. • Inherent toxicity: 140 pesticides considered neurotoxic, 37 used on food &/or feed.
    41. 41. Pesticides Pesticides and Health Associations noted with: – Neurodegenerative disorders • Parkinson's Disease – Birth defects – Neurodevelopmental disorders – – – – • Autism Spectrum Disorder (ASD) • Attention Deficit and Hyperactive Disorder (ADHD) Leukemia Non-Hodgkin’s lymphoma Soft tissue sarcoma Brain tumors • Same tumors repeatedly found in adult studies. Zahm SH, Ward MH., EHP 1998
    42. 42. Pesticides Background Pesticide Exposures Widespread • Reported use: 98% of families, 80% during pregnancy. • In Humans: detectable chlorpyrifos metabolites in 92% children’s, 82% adults’ urine. • Food: detectable residues of at least 1 pesticide on conventionally grown 72% fruits & vegetables. • In Homes: 3 to 9 pesticide residues found; 70% of infant levels from dust. • In Air: indoor levels 10 to 100X higher than outdoor. • In Water: >90% stream samples, 50% of wells.
    43. 43. Organophosphate Pesticides Pesticides Occurrence and distribution of 11 types in surface & ground water of the United States, 1992-97 http://ga.water.usgs.gov/publications/abstracts/ofr00-187.html
    44. 44. Pesticides Anthropological Study of Children Exposed to Pesticides Children from villages practicing organic agriculture Children from villages practicing non-organic agriculture
    45. 45. Pesticides Case: Transient Hypertonia in an Infant • 7lbs. 14 oz. term female, jaundice peak bili 12.6 • Normal physical exam at 12 weeks except lower extremity and hypertonicity • Pediatric consult at 16 weeks - upper and lower extremity hypertonicity, ankle clonus with diagnosis of cerebral palsy • Physical therapy begun • No environmental history was taken Wagner SL, Orwick DL., Pediatrics 1994
    46. 46. Pesticides 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 Wagner SL, Orwick DL., Pediatrics 1994
    47. 47. Anticipatory Guidance Card http://www.flickr.com/photos/andreasbalzer/433048027/ Pesticides
    48. 48. Pesticides Urban Exposure to Pesticides During Pregnancy Ubiquitous • NYC women wore backpack air samplers for 48 hrs during 3rd trimester • 266/314 reported pest measures at home (90% for cockroach) • ALL tested positive for exposure to at least 4 pesticides • Cord blood levels = maternal • Chlorpyrifos associated with decrease in BW and length Whyatt et al. Envir. Health Persp. 2002
    49. 49. Pesticides 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 malathion (left) and chlorpyrifos (right) • Again elevated on re-introduction of conventional diet Lu et al. 2006 EHP
    50. 50. Pesticides Advise Patients • • • • • Regularly clean areas where children play; Practice Integrated Pest Management (IPM) Use nontoxic products in yard; Clean/remove shoes outside; Buy organic food or, when unable, clean nonorganic produce; • Store food in secure nontoxic containers. • Select lawn care & pest control companies which use IPM and nontoxic products.
    51. 51. Pesticides Advice for Buying Organic: Pesticide Guides Institute for Agriculture and Trade Policy
    52. 52. Conclusions Emerging Themes • The more we learn about chemicals, the lower we shift the toxic “thresholds”. • Subtle effects carry profound impacts when expressed over a population (IQ). • Adverse effects of toxins are often synergistic-advisories based on analysis of a single chemical are unlikely to protect public health.
    53. 53. Conclusions Guiding Principles • Disabilities are widespread. Toxic exposures are preventable contributors. • Apparent toxicity at high doses is a red flag for possible harm from low dose exposures. • Since “proof” of harm materializes slowly, generations are being put at risk before adequate regulatory response occurs. • To protect public health, we need a flexible regulatory system capable of preventing (as well as responding to) exposures.
    54. 54. Conclusions What Can You Do? • Be aware of environmental toxins & possible effects. • Provide education on prevention and minimizing exposures - use the Pediatric Environmental Health Toolkit in your practice http://www.flickr.com/photos/cursedthing/2198948816/ • Advocate for a healthier environment
    55. 55. Acknowledgments • Greater Boston Physicians for Social Responsibility • Washington Physicians for Social Responsibility • Oregon Physicians for Social Responsibility • Ted Schettler, MD, MPH • Steven G. Gilbert, PhD, DABT • Richard Grady, MD • Catherine Thomasson, MD • Michelle Gottlieb • Jenny Pompilio, MD • Maria Valenti • Jill Stein, MD • David Wallinga, MD • Margie Kircher
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