Environment hazard

1. Pediatric Environmental
Hazards
Dr Mya Mya Chel
Senior Consultant Pediatrician
PU SGH

2. Introduction
• The past decade has been marked by a rapid
expansion of scientific inquiry, media reports,
and public interest in the topic of
environmental contaminants and child health
• Pediatricians & Doctors are increasingly called
on to answer of questions about environmental
health

3. Introduction
• preventing the potential adverse effects of
environmental contaminants in child health is
important bcos children are vulnerable due to '
they are not small adult.

4. Core Concepts in Pediatric
Environmental Health
• Children’s susceptibility to environmental
hazards differs from that of adults
• Injury prevention advice for a newborn is
unique from that given during an adolescent
visit

5. Disruption of Normal Developmental
Processes
• Maternal exposure in pregnancy to
teratogenic drugs, chemicals and infections
may result in structural or functional
anomalies
• Major organ development occurs in the
embryonic period, just 18 to 60 days
postconception and this period is a high-risk
window for structural anomaly development
such as the common birth defects

6. Disruption of Normal Developmental
Processes
• Organ system development, such as nervous,
pulmonary, and immune system function and
maturation, is a continuum that persists through
later gestation, postnatally and even into
adolescence
• Endocrine system changes in later childhood and
pubertal periods influence ongoing reproductive
system development
• Chemicals that alter these processes may
compromise the function of these organ systems

7. Disruption of Normal Developmental
Processes
• Chemicals that are associated with
carcinogenesis are also of high concern in
children because cells that undergo
carcinogenic transformation in childhood have
more time to develop into tumors

8. Disruption of Normal Developmental
Processes
• One well-described example of functional
developmental toxicity is lead exposure
• The current public health threshold for action
is a blood lead level (BLL) of 5 g/dL for a
pregnant woman and 10 g/dL (0.48 mol/L) for
a child, but 25 g/dL (1.21mol/L) is the
threshold for a nonoccupationally exposed
adult

9. Opportunities for Receiving Higher
Doses
• Because metabolic rate is largely influenced by
an organism’s size, children eat more food,
drink more water, and breathe more air than
adults on a per-kilogram body weight basis
• If food supplies, water or air contain a
contaminant, exposed children receive a
higher dose than adults

10. Opportunities for Receiving Higher
Doses
• Children have unique, life-stage-specific
behaviors that may influence their exposure
to environmental contaminants
• Unique feeding pattern partly explains the
vulnerability of Chinese infants who suffered
acute renal failure due to melamine-
contaminated infant formula in China in 2008

11. Opportunities for Receiving Higher
Doses
• Despite the detection of melamine in other foods
and dairy products, infants whose sole source of
nutrition was highly contaminated formula
received doses hundreds of times higher than
that received by older children or adults, who
consumed a variety of foods
• In older children eating idiosyncratic diets of
limited variety, if one of their primary foods is
contaminated, they are at risk for accumulating
relatively high exposures

12. Opportunities for Receiving Higher
Doses
• It is common for toddlers to explore nonfood
items orally
• The crawling child is in close contact with
surfaces indoors and out, increasing exposure to
contaminated dust, soil, or household products
as well as items such as lead paint
• This situation likely explains the observation that
peak BLLs in children typically occur at age 18 to
24 months, when mobility expands and oral
exploratory behaviors are still present

13. Commonly Identified Pediatric
Environmental Hazards
• Children may encounter environmental
contaminants in drinking water, food, inside
their homes, or in the community
• There are more than 80,000 chemicals in
commerce and hundreds of human pathogens

14. Commonly Identified Pediatric
Environmental Hazards
• Drinking Water Contaminants
• Food Contaminants
• Indoor Environment: Home, School, Child Care
• Outdoor Settings

15. Drinking Water Contaminants
• The Act also requires suppliers to provide an
annual report explaining the source of the
water, how it is treated, a list of the chemicals
for which it is tested, and the highest
concentration of each chemical found in the
past year
• If a serious problem is identified, public water
suppliers are required to inform consumers
quickly

16. Drinking Water Contaminants
• Private drinking water factory bear the
responsibility for their own wells, although
states provide guidance on construction,
maintenance, and testing ,regularly.

17. Drinking Water Contaminants
• The range of potential contaminants includes
chemical, microbiologic, and physical
(radiation)hazards
• Most commonly found and to which children may
be particularly vulnerable are
– Cryptosporidium
– Escherichia coli
– lead
– arsenic
– nitrates/nitrites
– trichloroethylene/perchloroethylene

18. Cryptosporidium
• One of the two most common microbiologic
water contaminants of concern for children
• Protozoan that causes severe gastroenteritis
and dehydration among infants or
immunocompromised individuals
• Due to its small size, standard water filtration
may be inadequate and boiling is required for
decontamination

19. Escherichia coli
• The presence of E coli in water is considered a
marker of recent sewage or animal waste that
may contain disease causing organisms
• Although most strains of E coli are harmless and
commensal in healthy mammals, E coli 0157:H7
produces a powerful toxin and can cause severe
hemorrhagic enterocolitis
• Children younger than 5 years of age are at risk of
hemolytic-uremic syndrome (HUS) as a
complication

20. Lead
• One of the most important pediatric
environmental health concerns, and that 20%
of a child’s lead exposure is attributable to
water
• Although rarely found in source water, lead
leaches into drinking water from lead-
containing plumbing materials, lead pipes, or
lead-containing solder or fixtures

21. Lead
• This fact underlies practical recommendations
for running the faucet for 2 minutes or until
the water turns cold to ensure that the water
in a system is “flushed”
• Removing water that has had long-standing
contact with plumbing components avoids
consumption of water that contains higher
concentrations of leached lead

22. Lead
• Improper remediation and repair of surfaces
that contain lead-based paint or disruption of
asbestos insulation on pipes, boilers, or
furnaces may result in concerning indoor
exposures
• Deteriorating lead-containing paint is the most
common cause of lead poisoning in young
children

23. Arsenic
• In some regions, source water comes in
contact with bedrock, soil, or sediment that
contains naturally occurring arsenic
• Arsenic is a known human carcinogen and it
may also be a neurodevelopmental toxicant

24. Nitrate
• Common contaminant in well water from
sewage contamination or agricultural use of
fertilizer
• Presence of nitrate is an indication for testing
for coliforms; lack of coliforms indicates the
source is fertilizer

25. Nitrate
• Young infants are at risk for developing
methemoglobinemia, which results from
conversion of nitrate to nitrite in their
stomachs
• With age, stomach acidity increases, reducing
the numbers of nitrite-producing bacteria
• After age 6 months, the conversion of nitrate
to nitrite in the gut is greatly reduced

26. Chlorinated solvents
• Trichloroethylene and perchloroethylene are
commonly used industrial solvents
• More than 400,000 sites in the United States
contain soil and ground water contaminated
by chlorinated solvents
• Low-level chronic exposure - increased cancer
risk and both compounds are liver and kidney
toxicants

27. Bisphenol A (BPA)
• Emerging contaminant of concern that may
leach into water or food from plastic container
materials
• The Centers for Disease Control and
Prevention (CDC) identified BPA in 93% of
Americans sampled (age 6 years and older)

28. Bisphenol A (BPA)
• The finding raises concern based on animal
studies that have linked prenatal exposure to
this weakly estrogenic compound with
neurotoxicity, early puberty, mammary
tumors, prostate hypertrophy, and increased
adiposity and body weight

29. Food Contaminants
• Food-borne infections pose an ongoing public
health challenge
• Most are associated with acute enterocolitis that
may be mild to severe
• Most concerning food-borne chemical
contaminants for children are
– pesticide residues
– contaminants that concentrate in some fish, including
mercury and chlorinated hydrocarbons such as
polychlorinated biphenyls (PCBs)

30. Food Contaminants
• health concerns - potential chronic health
conditions, such as compromised cognitive or
behavioral development and cancer
• In addition to BPA, phthalates are
contaminants of emerging concern that may
leach from plastic packaging materials into
food

31. Pathogens
• The predominant foodborne pathogens are
Salmonella, Campylobacter jejuni/coli,
Toxoplasma gondii, and Norwalk virus
• Listeria monocytogenes and E coli 0157:H7 are
of particular concern for newborns and
children

32. E. coli
• E coli 0157:H7 produces toxin
• infection often is accompanied by severe
abdominal cramps, diarrhoea (often bloody), and
vomiting
• If there is fever, temperature is usually not very
high(38.5°C)
• Approximately 5% to 10% of those in whom E coli
0157:H7 infection is diagnosed develop HUS, with
young children at higher risk for this severe
complication

33. Listeria
• Listeria poses a risk to the fetus and newborn of
an infected mother because pregnant woman
have an approximately 20-fold increased risk of
listeriosis
• Infection manifests with fever, muscle aches, and
sometimes gastrointestinal symptoms such as
nausea or diarrhea
• With spread to the central nervous system,
symptoms such as headache, stiff neck,
confusion, loss of balance, and seizures can occur

34. Pesticide
• Pesticide chemicals comprise a broad group
that has varying types and levels of toxicity
• Concern for impaired neurologic
development,parkinsonism, immune system
effects, endocrine disruption, and increased
cancer risk

35. Pesticide
• Emerging epidemiologic studies suggest that
children who have had higher in utero
exposure to organophosphate pesticides in
both urban and agricultural settings are at
increased risk for abnormal
neurodevelopment

36. Pesticide
• In addition to exposure from indoor pest
control or proximity to agricultural production,
children can be exposed to these chemicals on
some fruits that are common dietary staples

37. Fish
• Fish is an important source of nutrients for
children but may contain contaminants that
outweigh this benefit
• In 2004, the EPA and the FDA issued targeted
advice concerning mercury in fish for women
who might become pregnant, women who are
pregnant, nursing mothers, and young children
• The recommendations outline selecting and
eating fish or shellfish that maintain the benefits
of fish eating while reducing exposure to the
harmful effects of mercury

38. Fish
• In addition to the well established
neurodevelopmental toxicant mercury, most
advisories involve highly lipid-soluble
organochlorines such as PCBs, chlordane,
dioxins, DDT, and brominated flame retardant
chemicals such as PBDE (polybrominated
diphenyl ethers)

39. Fish
• These chemicals persist in the environment
and can bioaccumulate as they move up the
aquatic food chain
• In some cases, preparation and cooking
techniques to reduce consumption of the
lipid-rich fish components can reduce levels of
contaminants significantly

40. The Healthy Indoor Environment: Home,
School, Child Care
• Children spend most of their time in indoor
settings, particularly their homes (85% of
time), followed by school or child care
• Although the importance of addressing
tobacco smoke or pet allergen is familiar to
most clinicians, the indoor environment is a
primary source for several other hazardous
exposures

41. The Healthy Indoor Environment: Home,
School, Child Care
• More than 90% of the 2 million poisonings
reported to national poison centers each year
occur in the home
• Household cleaning agents, pesticides that
include insect killers and lawn and garden
products, and automotive products may
contain acutely toxic components that pose a
poisoning risk if not stored safely

42. The Healthy Indoor Environment: Home,
School, Child Care
• These chemical [pesticide ] products may
represent insidious exposures that occur as
daily low-level doses and may increase chronic
health risks such as asthma or cognitive and
behavioral problem

43. Mold
• leaks and water damage that give rise to
excess mold or other microbial growth may
result in upper respiratory tract (nasal, throat)
symptoms, cough, wheezing, and asthma in
sensitized individuals
• Clues to excessive mold exposure include a
known water leak or damage, mildewy odor,
and visible water damage or mold growth on
household surfaces such as walls or ceilings

44. Lead
• Improper remediation and repair of surfaces
that contain lead-based paint or disruption of
asbestos insulation on pipes, boilers, or
furnaces may result in concerning indoor
exposures
• Deteriorating lead-containing paint is the most
common cause of lead poisoning in young
children

45. Lead
• Lead dust can form when lead-based paint is
dry scraped or heated and when painted
surfaces bump or rub together
• Lead dust accumulates in windowsills, on
floors, and in soil
• Low-level lead exposure is associated with a
reduced intelligence quotient and behavioral
problems, including attention-
deficit/hyperactivity disorder (ADHD)

46. Lead
• Improper remediation and repair of surfaces
that contain lead-based paint or disruption of
asbestos insulation on pipes, boilers, or
furnaces may result in concerning indoor
exposures
• Deteriorating lead-containing paint is the most
common cause of lead poisoning in young
children

47. Lead
• Improper remediation and repair of surfaces
that contain lead-based paint or disruption of
asbestos insulation on pipes, boilers, or
furnaces may result in concerning indoor
exposures
• Deteriorating lead-containing paint is the most
common cause of lead poisoning in young
children

48. Radon
• Radon is estimated to cause approximately
21,000 lung cancer deaths each year
• Radon comes from the radioactive decay of
naturally occurring uranium in soil, rock, and
water that can infiltrate into homes through
cracks and other holes in the foundation

49. Carbon monoxide
• Improper or inadequate ventilation that
allows buildup of carbon monoxide from
household combustion sources (eg, furnace,
fireplace, attached garage) may cause health
consequences ranging from mild nuisance
symptoms to fatalities

50. Carbon monoxide
• Clues to such exposures include an environmental
history that identifies potential sources of carbon
monoxide, clustering of symptoms among
individuals who spend most time in the affected
areas, and symptom worsening and relief
associated with entering and leaving specific
environments
• Discussion of a functional carbon monoxide
detector should be a part of routine anticipatory
guidance

51. Take-home pathway
• Exposures encountered by household
members at work may be brought home as
dust or residues on clothing and shoes
• It is important to become familiar with the
occupations of patients and household
members and ask about potential toxic
exposures

52. Take-home pathway
• If there are questions about chemicals in the
workplace, employers are required by law to
provide material safety data sheets, which
offer information on the chemical constituents
of products that are used
• Hygiene practices of removing work clothes
and shoes and showering before entering the
home can reduce the “take-home” pathway

53. Phthalates
• Recently, concern for exposure to phthalates
in soft plastic consumer products such as toys
and personal care products for children
(lotions, shampoos, diaper creams) has
emerged
• These antiandrogenic chemicals can affect
androgen-sensitive tissues adversely during
specific windows of development

54. Phthalates
• Both animal and human studies suggest that
exposure may compromise normal male
reproductive system development and
function
• Preliminary data also link these chemicals to
allergic disease

55. The Healthy Community and Outdoor
Settings
• Community characteristics, such as proximity
to pesticide-treated agricultural fields, high-
traffic roadways, industrial sites, or waste
sites, should be assessed for the areas where
children spend time during outside activities
• Children may encounter exposures at a
workplace (eg, teen workers or young children
of farm workers brought to fields)

56. The Healthy Community and Outdoor
Settings
• Community ozone concentrations typically are
maximal in the late afternoon, a time when
children participate in outdoor play and sports
activities
• The Air Quality Index can provide local
information on daily air quality and help guide
decisions on outdoor activities
• Playground or decking equipment made with
copper chromated arsenic-treated wood may
increase a child’s exposure to arsenic

57. The Healthy Community and Outdoor
Settings
• Some ambient pollutants permeate readily
into the indoor environment, such as traffic-
derived fine particulate air pollution
• Traffic-related pollutant concentrations are
much higher within 150 to 300 m of major
roadways and highways and drop off rapidly
with increasing distance

58. The Healthy Community and Outdoor
Settings
• In studies of farm worker children, those living
closer to treated fields showed higher levels of
exposure to pesticides, based on urinary
metabolites measurements, than their peers
who lived further away (200 m)
• Concentrations of pesticides in household
dust exceeded concentrations in soil,
demonstrating the “take-home pathway”

59. The Healthy Community and Outdoor
Settings
• Pets and people can track pesticide residues
from treated fields or lawns indoors and
contaminate surfaces where children crawl
and play
• Knowledge of environmental hazards in the
community can help in the creation of
prevention messages and community
improvements that promote healthier
residences, schools, and play areas

65. Emerging Knowledge and Risk
Communication
• Studies link chronic, routine, low-level
exposures to environmental factors with many
of the major current chronic pediatric
morbidities, such as asthma, obesity, ADHD,
learning disabilities, birth defects, cancer, and
low birthweight or preterm birth

66. Emerging Knowledge and Risk
Communication
Pediatricians
• are a trusted source of reliable information
• play an important role in providing
reassurance, allaying fears and anxiety, and
avoiding misplaced resources

67. Summary
• Pediatricians are a trusted, desired, and
important source of information on
environmental health topics
• It is well established that children are more
vulnerable to environmental contaminants
due to their rapid and ongoing growth and
development and potential for higher
exposures based on behavioral and
physiologic differences

68. Summary
• Evidence and consensus highlight the importance
of the environmental history in identifying and
reducing children’s exposure to hazardous
contaminants
• There is sufficient evidence that lead exposure is
common among United States children and that
concentrations below the current action level
(BLL >10 g/dL [ 0.48 mol/L]) are associated with
adverse effects on neurodevelopment and
behavior

69. Summary
• A joint federal advisory from the FDA and the EPA
recommends reducing exposure to mercury by
highlighting the importance of selecting fish that
contain lower concentrations of methylmercury
• Multiple studies identify risks in the indoor
environment that reflect housing quality, choice
of building sites, and exposures that include lead
from paint or water, asbestos, radon, particulate
matter, mold, pesticide use patterns, and carbon
monoxide

70. THANK YOU