Child health & environment

19 APR 07 Dr. M. S. Prasad 1
EnvironmentEnvironment
&&
Child HealthChild Health
Dr. M. S. PrasadDr. M. S. Prasad
Consultant & Head
Dept. of Paediatrics
Safdarjung Hospital &
Vardhaman Mahavir Medical College
New Delhi

Environmental Hazards andEnvironmental Hazards and
their relationship to Healththeir relationship to Health
A neglected topic in the
Paediatric and General
Medical Textbooks.

HistoryHistory
• 1954:1954: Nuclear weapon test on Bikini IslandBikini Island
– Acute burns from beta-radiation in the neighboring islands.
– Hypothyroidism,
– Thyroid neoplasm, and
– Leukemia.
• 1957:1957: AAP CommitteeAAP Committee on Radiation Hazards and Congenital
Malformations.
• 1961:1961: CommitteeCommittee on Environmental Hazards.
• 1966:1966: First International ConferenceConference on Paediatric significance on
nuclear fall-outs.
• 1973:1973: ConferenceConference on the Susceptibility of the Fetus and Child to
Chemical Pollutants.
• 19811981:: ConferenceConference on Chemical and Radiation Hazards to Children.
• 1991:1991: CommitteeCommittee on Environmental Health.

HistoryHistory (Continued)
• 1996:1996: Food Quality Protection Act.
• April 21, 1997:April 21, 1997:
President Clinton issued Executive Order 13045: Protection of
Children from Environmental Health Risks and Safety Risks.
• October 1999:October 1999: First edition of the AAP
“Handbook of Pediatric Environmental Health”.
• 2000 & 2001:2000 & 2001: Workshops.
• 2002:2002: The Ambulatory Pediatric Association launched
3 years fellowship training programmefellowship training programme..

EnvironmentEnvironment
The term environment implies allThe term environment implies all
the external factors – living andthe external factors – living and
non-living, material and non-non-living, material and non-
material – which surround man.material – which surround man.
Everything except me is environment.
The term environment implies allThe term environment implies all
the external factors – living andthe external factors – living and
non-living, material and non-non-living, material and non-
material – which surround man.material – which surround man.
Everything except me is environment.

ClassificationClassification
• Physical:
– Macro-environment
– Microenvironment.
• Biologic:
Plant & animal life including bacteria, viruses, insects,
rodents and animals (including man).
• Social:
– Customs, culture, habits, income, occupation, religion etc.
• Chemical: Pesticides, Fluorine, Mercury, Lead, Solvent.

Areas of concernAreas of concern
• Physical:
– Radiation,
– Noise,
– Extreme heat/cold,
– Unsafe building,
– Traffic……..
• Chemical:
– Pesticides,
– Solvents,
– Lead,
– Mercury……….
• Biological:
– Disease Vector,
– Mould,
– Envenoming ……….

Why children?Why children?

Environment & DiseasesEnvironment & Diseases
• More than 1/4th
of global disease burden is
due to modified environmental factors.
• It is 1/3rd
of Paediatric Diseases burden.
[WHO, Preventing diseases through healthy environment 2000]

1. Different and unique exposures
2. Dynamic developmental physiology
3. Longer life expectancy
4. Politically powerless
Raphael, National Gallery of Art, Washington, DC
CHILDREN ARE NOT LITTLE ADULTSCHILDREN ARE NOT LITTLE ADULTS

1. DIFFERENT AND UNIQUE EXPOSURESDIFFERENT AND UNIQUE EXPOSURES
 Unique exposure pathways
– Transplacental
– Breastfeeding
 Exploratory behaviours leading to exposures
– Hand-to-mouth,
– Object-to-mouth
– Non-nutritive ingestion
 Stature and living zones, microenvironments
– Location – lower to the ground
– High surface area to volume ratio
 Children do not understand danger
– Pre-ambulatory
– Adolescence – “high risk” behaviors

Moore, Elsevier Inc, 1973
WINDOWS OF DEVELOPMENT

TRANSPLACENTAL EXPOSURETRANSPLACENTAL EXPOSURE
Maternal exposures do matter!
Lessons from pharmaceuticals: thalidomide, diethylstilbestrol (DES), alcohol

Breast-feedingBreast-feeding
Pollutants that may be
found in Human Milk
Chemical AgentsChemical Agents
DDT, DDE
PCB/PCDF
Dioxin
Chlordane
Heptachlor
Hexachlorobenzene
Volatile Organic Compounds
Nicotine
Metals
Lead
Methylmercury.

Breast-feedingBreast-feeding
• Halothane has been detected in the
milk of lactating anaesthesiologistanaesthesiologist..
• There is a single case of report of a child developed cholestatic
jaundice while being breastfed. His mother lunched daily with her
husband, who was a dry-cleaner, and perchloroethylene was found
in her milk.
Ref.:
– Br. J. Anaesth. 1976; 48-541 – 543.
– Can Med Assoc J 1977; 117: 1047 – 1048.

pembe yarapembe yara
• Weakness,
• Convulsions, and
• An annular papular rash.
• Case Fatality Rate: 95%.
• Cause: hexachlorobenzene in human milk.
• Turkey: 1957-59

Breathing ZonesBreathing Zones
• For an adult = 4 to 6 feet above the floor.
• For a child = closer to the floor.
• Chemicals heavier than air concentrate within lower
breathing zones near the floor.

Adult versus ChildrenAdult versus Children
• Microenvironment can differ enormously between
adults and children.
• Imagine a room which has air contaminated with mercury.
• Air near the floor may have a higher concentration
of mercury than air near the ceiling.
• The microenvironment of an infant lying on the floor therefore
would be different from that of a standing adult.

0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
Surface Area/Body Mass
Newborn
Toddler
Child
Adult
SIZE AND SURFACE AREA

 Children lack the cognitive ability to recognize hazardous
situations.
 Pre-ambulatory children are unable to remove
themselves from danger
 Pre-reading children cannot read warning signs & labels
 Pre-adolescent / adolescent children may take unreasonable
risks due to cognitive immaturity and "risk-taking"
behaviours [Amir Khan in a film]
CHILDREN / ADOLESCENTS DO NOT RECOGNIZE DANGER

2. DYNAMIC DEVELOPMENTAL PHYSIOLOGY
Xenobiotics may be
handled differently by
an immature body
WHO
MORE VULNERABLEMORE VULNERABLE

3. LONGER LIFE EXPECTANCY
A safe and healthy environmentA safe and healthy environment
leads to a longer life expectancy.leads to a longer life expectancy.
WHO
Children inherit the world WE make!

4. POLITICALLY POWERLESS
 No political voice
 Advocacy by health sector
 Environmental laws and
regulations
– Local
– National
– International
WHO

SEARO, HRIDAY Educational Company
ENVIRONMENTAL RISK FACTORS AND CHILD LABOURENVIRONMENTAL RISK FACTORS AND CHILD LABOUR
 Over 171 million of the
352 million children
aged 5 – 17 years,
who work as Child
Labour, are exposed
to hazardous
conditions, including
chemical exposure
and poisoning.
 Child Abuse &
Neglect is another
environmental hazard
created by mankind.

WATER

Oh!Oh! The beautiful blue!

WATER IS ESSENTIAL FOR LIFE
 Access to safe water and sanitation
is a universal need and a basic
human right.
 70% of earth’s surface is water
 Only 2.5% to 3% is fresh water
 Less than 1% is accessible
 Pollution and other factors further
reduce access by 2/3
 1.1 billion people (1/6th
of the world’s
population) have no access to quality
drinking water Earth Observatory, NASA

wwwga.usgs.gov/edu/waterdistribution.html

Reykjavik

UNEP

Waterborne diseasesWaterborne diseases
 Cholera
 Poliomyelitis
 Diarrhoeal diseases
 Roundworm
 Enteric fevers: typhoid
 Whipworm
 Hepatitis A
 Cryptosporidium
 Giardia
Water-washed diseasesWater-washed diseases
 Scabies
 Typhus
 Trachoma
 Louse infestation
Water-based diseasesWater-based diseases
 Schistosomiasis
 Dracunculiasis (guinea-worm)
Diseases transmitted by
water-related insect vectors
 Malaria
 Onchocerciasis
 Yellow fever
 Dengue
 Filariasis
 African trypanosomiasis
 Leishmaniasis
 Japanese Encephalitis
WATER - RELATED INFECTIONSWATER - RELATED INFECTIONS

 From natural erosion, discharge
from fertilizer and aluminium
factories, or added to drinking-water
 Bone disease, mottled teeth
 WHO guideline: 1.5 mg/L (ppm)
INORGANIC CHEMICAL: FLUORIDE (FL)INORGANIC CHEMICAL: FLUORIDE (FL)
A. K. Susheela. Fluorosis Research & Rural Development Foundation of India

Indoor HazardsIndoor Hazards..

SICK BUILDING SYNDROMESICK BUILDING SYNDROME
What is this syndrome?
 Discomfort not related to specific illness
 Effects appear to be linked to time spent inside the building
 Cause of symptoms is unknown
 Most complaints relieved soon after leaving the building
Building related illness:
Symptoms of identified illness attributed to airborne
contaminants in the building.

FIREFIRE
 Fire injuries can result from
Inhaled toxic chemicals and/or
Thermal burns.
 Make your home safer:
 Beware of matches and lighters
 Install smoke alarms
 Have a home fire escape plan

DUST MITESDUST MITES
CDC

MOULDMOULD
Occurs in dampOccurs in damp
indoor spacesindoor spaces
This home suffered only minor
exterior damage from
Hurricane Katrina, however
small leaks during the storm and
inadequate air flow, as the
house was vacant for weeks,
permitted this mold infestation
and resulted in homeowners
returning to this scene.

INDOOR AIR POLLUTIONINDOOR AIR POLLUTION

CHILDREN’S UNIQUE VULNERABILITYCHILDREN’S UNIQUE VULNERABILITY
 Inhale more pollutants per kilogram of body weight than do adults
 Because airways are narrower, irritation can result in
proportionately greater airway obstruction
WHO

Diagram showing effect of oedema onDiagram showing effect of oedema on
the cross-sectional airway diameterthe cross-sectional airway diameter
(R= radius)
Adult Airway
• D = 20 mm R = 10 mm
• Area = ∏ R2
= ∏ 102
= 100 ∏ mm2
(Normal)
• Oedema = 1 mm
• Area = ∏ 92
= 81 ∏ mm2
(81% of Normal)
Full Term Newborn
• D = 6 mm R = 3 mm
• Area ∏ R2
= ∏ 32
= 9 ∏ mm2
• Oedema = 1 mm
• Area = ∏ 22
= 4 ∏ mm2
(44% of Normal)
www.vh.org/pediatric/provider/pediatrics/ElectricAirway/Diagrams/AirwayDIaneterEdema.jpg

INDOOR AIR POLLUTION ALSO
AFFECTS OUTDOOR AIR QUALITY
Nigel Bruce/ITDG

SMOKY COOKING FUELS
WHO

CARBON MONOXIDE: THE "SILENT KILLER"
A COMMON CAUSE OF ACUTE AND LETHAL POISONING
www.cdc.gov/nceh/airpollution/carbonmonoxide/checklist.htm

CARBON MONOXIDE (CO): SOURCES
 Gas, kerosene, wood stoves and coal
 Room and water heaters
 Fireplaces, furnaces
 Leaking chimneys and vents
 Vehicle exhaust in closed garage
 Tobacco smoke
Any place where combustion is incomplete
EPA

Second-Hand Tobacco SmokeSecond-Hand Tobacco Smoke
(SHTS)
Children whose mothers smoke
 70% more respiratory problems
 Pneumonia and hospitalization in year 1 is 38% higher
 Infant mortality is 80% higher
 20% of all infant deaths could be avoided if all pregnant
smokers stopped by the 16th week of gestation
 5 times higher risk of sudden infant death syndrome (SIDS)

MOSQUITO COILSMOSQUITO COILS
 Major active ingredient –
PyrethrinsPyrethrins
 Long-term exposures linked
to asthma and wheezing
ehp.niehs.nih.gov/members/2003/6177/6177.html

RADONRADON
 Radon is a radioactive gas released from
soil and rocks
 It is the second leading cause of lung cancer
 Indoor Radon concentrations depend on
construction site and building materials
 Highest levels occur in basements and on the
ground floor

RADON MITIGATION SYSTEM
A – Gas-permeable layer
B - Plastic sheeting
C - Sealing and caulking
D - Vent pipe
E - Junction box
It is recommended thatIt is recommended that
homes be tested for radonhomes be tested for radon
on the lowest lived-in level –on the lowest lived-in level –
basement or ground floorbasement or ground floor
www.epa.gov/iaq/radon/construc.html

Radon in schoolsRadon in schools
Schools should also be tested for radon
Levels above 4 pCi/L call for action to reduce exposure
www.epa.gov/radon/pubs/schoolrn.html

ASBESTOSASBESTOS
Sources:
 Building construction materials used for insulation and as a fire-
retardant: asbestos cement, floor tiles, water pipes and others
 Levels increase if asbestos-containing materials are damaged
Health effects:
 NO acute toxicity
 Asbestosis results from occupational exposure
 Main risk for children: long-term exposure may cause cancer
 Lung cancer
 Malignant mesothelioma

LeadLead

LEAD POISONING IN THE ANCIENT WORLD
Did lead poisoning contribute to the fall of Rome?Did lead poisoning contribute to the fall of Rome?
In the Roman Empire, the upper classes were
exposed to high contents of lead in wine.
Lead water pipes
Glazed pottery
Signs and symptoms of lead poisoning recognized in
about half of the 38 Roman emperors
Nriagu, N Engl J Med. 1983 Mar 17;308(11):660

WHO ESTIMATESWHO ESTIMATES
 12 million children in developing countries suffer
from some form of permanent brain damage from
lead poisoning
 Hundreds of millions of children and pregnant
women are exposed to different sources of lead
 Worldwide, about 3.5% of minor mental retardation
is attributable to lead poisoning

X-RAY OF RECENT
LEAD INGESTION
A plain (flat) abdominal film
of a toddler with a recent
ingestion of lead-containing
paint chips
Lead particles are evident as
radio-opacities
Courtesy of John Graef, MD, Boston Children's Hospital

BASOPHILIC STIPPLING
 Classical laboratory
sign known since 1899
 Inclusions of
aggregated ribosomes
found only in the red
blood cells
 Unspecific and
inconstant

THE “LEAD LINE” SIGN
Abnormally heavy
mineralization of the
growth plate of long bones
in X-ray
The width and density of
“lead lines” reflect chronic
exposure

LEADED PETROL – MAJOR SOURCELEADED PETROL – MAJOR SOURCE
Institute of Medicine, EPA, 1996

PESTICIDESPESTICIDES
Children's Health and the Environment
World Health Organization
www.who.int/ceh
August 2006 version

PESTICIDES – EXPOSURE
 Problems of spraying pesticides at home and in schools
 Higher concentrations near the floor
 Persistence in some surfaces: carpets, soft toys, …
 Overuse and misuse of pesticides
 Children’s behaviour and inhalation of pesticides
 Crawling
 Playing close to the floor
 Hand-to-mouth
 Object-to-mouth

CHILDREN'S EXPOSURECHILDREN'S EXPOSURE
WHO

Abusing DDT...
Norsk Barnemuseum
 DDT, DDE and their metabolites are weak
oestrogens and anti-androgens.
 Metabolites:
 o, p’ DDT
 p, p’ DDE
 Prenatal exposure to metabolites was
associated with a delay in mental and
psychomotor development at 13 months.

Persistent OrganicPersistent Organic
Pollutants (POPs) &Pollutants (POPs) &
Endocrine Disruptors.Endocrine Disruptors.
Children's Health and the Environment
World Health Organization
www.who.int/ceh
August 2006 version

WHAT ARE "POPs" ?
 Synthetic organic chemicals
 Persistent in environment
 Long-range transport leads
to global pollution
 Lipophilic
 Accumulate in food-chain
 High levels in fish and marine
mammals
Acute toxicity well-characterizedAcute toxicity well-characterized
NOAA

PESTICIDES
Aldrin
Dieldrin
Chlordane
DDT
Endrin
Heptachlor
Mirex
Toxaphene
INDUSTRIAL CHEMICALS
PCBs
HCB
UNINTENDED BY-PRODUCTS
Dibenzodioxins
Dibenzofurans
PERSISTENT ORGANIC POLLUTANTS (POPs)
Stockholm Convention: a global treaty
ratified by the international community lead by
UNEP – calls for the elimination and/or phasing
out of 12 POPs www.chem.unep.ch/pops/default.html

POPs – INDUSTRIAL CHEMICALS
PCBs:
Polychlorinated biphenyls
Trade Names for different mixtures (partial list):
Aroclor, Pyranol, Pyroclor, Phenochlor,
Pyralene, Clophen, Elaol, Kanechlor,
Santotherm, Fenchlor, Apirolio, Sovol
HCB:
Hexachlorobenzene
White monoclinic crystals or crystalline solid
UNEP
UNEP

PCB: HUMAN HEALTH INCIDENTS
"YUSHO" "YU-CHENG"
Adverse, persistent effects in newborns
• Low birth weight
• Reduced growth
• Hyperpigmentation
• Gingival hyperplasia
• Eye oedema
• Dentition at birth
• Skull calcifications

Dietary route of exposure to PCB
MARINE
MAMMALS
Whale
Seals
OTHER
Vegetables
Cereals
Fruits
ANIMAL
FAT
Meat
Poultry
COW'S
MILK
Butter
Dairy products
FISH
Salmon
Eel
Shellfish
Fish liver
Fish oils
WHO

BEYOND THE "DIRTY DOZEN"…
 In addition to POPs, other chemicals are characterized by their
persistence in the environment
 Persistent Toxic Substances (PTSs)
 Can be transported long distances
 Can accumulate in organisms and enter food-chain
 Not "POPs" – not listed in the Stockholm Convention
 Could include: mercury, cadmium, lead, polybrominated
diphenyl ethers (PBDE – flame retardants), others

Semi-persistent organic pollutants
Found in sewage, generated by waste incineration and traffic
PAHs, Phthalate esters, PBDEs, PCNs, BPA, Alkylphenols
Corra, Ceppi

In animals:
 Chloracne
 Lymphatic alteration
 Liver effects
 Gastric lesion
 Epidermal lesions
 Chicken: oedema, ascites
 Rats: fetal death and resorption,
endocrine alterations
 Mice: embryotoxicity,
malformations
IARC classification: carcinogen
AN EXAMPLE: DioxinDioxin – health effects
In humansIn humans::
 Chloracne
 Polyneuropathy
 Hepatomegaly
 Fatigue
 Depression
 Porphyria
IARC classification: 2,3,7,8-TCDD is a
possible human carcinogen (Group 2B)

Chemicals that mimic hormones could alter
the differentiation of some tissues.
Because organ systems in children, including
the reproductive system, continue to
differentiate, such chemical may have effect
on the development of those organs.
Such substances/chemicals are known as
“Endocrine Disrupting Chemicals (EDC)” or
Endocrine Disruptors.
ENDOCRINE DISRUPTING CHEMICALS (EDCs)

WHO
Children represent the future of nations.

Recognize, Prevent,
Assess and Manage
diseases linked to, or
triggered by,
environmental factors.

PaediatricPaediatric
EnvironmentalEnvironmental
HistoryHistory

• A set of basic and concise questions
• Part of the standard medical history
with additional questions to find out
child’s possible exposure to
hazardous environment.
• Tailored according to the local
situation, needs and capacities of:
– Industrialized countries
– Developing regions
WHAT IS THE PWHAT IS THE PAAEDIATRIC ENVIRONMENTAL HISTORYEDIATRIC ENVIRONMENTAL HISTORY
WHO

1. What are the potential
environmental hazards?
2. How, when and where are
children exposed?
3. What are the main effects?
KEY AREAS TO ADDRESS
WHO

OBJECTIVESOBJECTIVES
Help PaediatriciansHelp Paediatricians
• To understand the child’s
physical surroundings, and
• To offer appropriate suggestions
to promote a healthy environment.

Some Basic QuestionsSome Basic Questions
1. Where does the child live or spend time?
2. Does anyone in the home smoke?
3. What is source of drinking water?
4. Are there exposures from items in the diet?
5. Is the child protected from excessive sun
exposure?
6. What do parents/teenagers do for a living?

WHO
"Agreenpageintheclinicalrecord"

EXAMPLES OF QUESTIONS: WHERE DOES THE CHILD LIVE?
• What is the building made of (e.g. wood, brick, mud, cardboard,…)?
• Is there mould on the walls? Is it well-ventilated? Are there any odours?
• Has there been any recent painting or refurbishing?
• Do family members smoke at home? What do they smoke ? How much?
• Are pesticides used indoors? How? Are there cockroaches? Mites? Rats?
• Are there pets (dogs, cats, birds) or other animals?
• How often is the place cleaned? Which chemicals are used for cleaning?
• Where/how is the cooking done? How is the home heated? Stoves? Exhaust?
[Same applicable to playground and school]

EXAMPLES OF QUESTIONS: WHAT ARE THE CHILD'S ACTIVITIES?
Hobbies
Painting – paint and solvents?
Model-building – glue and solvents?
Pottery – pigments, paints?
Gardening – pesticides?
Woodwork – chemicals?
Activities
Eating habits (type of
diet, food quality)
Drinking habits (alcohol
use and abuse, soft
drinks)
Playing habits
Learning habits
Working habits
Scavenging (time spent
near garbage)
Exploring
Testing (trying drugs,
eating unknown
berries)
Sports
Type of sport
Sports area
Injuries
Toxic exposures
Use of energizing drugs
Application of poultices
WHOWHO

EXAMPLES OF QUESTIONS:EXAMPLES OF QUESTIONS: CHILD'S BEHAVIOURS?CHILD'S BEHAVIOURS?
Personal hygiene and
habits
How often does the child bathe?
Hand and face washed? How?
Where? With what?
Are clothes washed regularly?
What type of diapers are used?
Does the child have lice? How is
it treated?
Does the child play on the floor?
Carpet? Soil?
How and how often are the
child’s bedroom and play area
cleaned?
Which chemicals are used to
clean the home?
Does the child have pica?
Cultural history
Use of alternative
medicines or cosmetics
Cultural practices
Religious practices
Traditions involving the
use of chemicals
Transport
What transport does the
child use?
- individual or collective;
- bicycle;
- motorcycle;
- horse; or other?
Characteristics of bus?
Bus stop?
WHO

www.atsdr.cdc.gov/HEC/CSEM/pediatric/index.html

Some related websitesSome related websites
• http://www.atsdr.edc.gov
• http://www.aoec.org
• http://www.aoec.org/PedEnvHx_
files/frame.htm
• http://children.cape.ca
• http://children.cape.ca/history.html

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