Pediatric Environmental Health - iowapha.org Pediatric EH.pdf · Pediatric Environmental Health Jennifer A Lowry MDJennifer A. Lowry, MD ... Poor nutrition neighborhood No parks 8

Pediatric Pediatric Environmental HealthEnvironmental Health

Jennifer A Lowry MDJennifer A. Lowry, MDDirector, Mid-America Pediatric

E i t l H lth S i lt U itEnvironmental Health Specialty UnitMedical Director, Center for

Environmental Health

©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13

No DisclosuresNo DisclosuresNo DisclosuresNo DisclosuresThis presentation was prepared by theThis presentation was prepared by the

Association of Occupational and E i t l Cli i (AOEC) dEnvironmental Clinics (AOEC) and funded (in part) by the cooperative agreement award number 1U61TS000118-04 from the Agency for g yToxic Substances and Disease Registry (ATSDR)


(ATSDR).

Learning ObjectivesLearning Objectivesg jg j

• How has Pediatric Environmental Health evolved and what is it at present?

• Understand physiological and behavioral differences• Understand physiological and behavioral differences that make children more vulnerable to toxic exposures than adults

• Appreciate how ongoing epidemiological and• Appreciate how ongoing epidemiological and toxicological studies have altered our concept of what is “acceptable” exposure K h t th iti t ib t f th• Know what are the positive contributors from the environment, and what is our legacy


3

What is Pediatric Environmental Health?


4

Pediatric Environmental Pediatric Environmental H lthH lthHealthHealth

A discipline that involves the identification, treatment, prevention and control of environmental exposures and associated adverse health effects inassociated adverse health effects in infants, children, adolescents, and young adultsyoung adults

http://www.aap.org/healthtopics/environmentalhealth.cfm


5

Whoever wishes to investigate medicine properly shouldWhoever wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year, and what effects each of them produces for they

t t ll lik b t diff h f th l iare not at all alike, but differ much from themselves in regard to their changes. Then the winds, the hot and the cold, especially such as are common to all countries, andcold, especially such as are common to all countries, and

then such as are peculiar to each locality. In the same manner, when one comes into a city to which he is a

stranger he o ght to consider its sit ation ho it lies as tostranger, he ought to consider its situation, how it lies as to the winds and the rising of the sun; for its influence is not the same whether it lies to the north or the south, to the rising or to the setting sun.—Hippocrates (“Airs, waters,

and places.” Approx. 350 BC)


Examples of Important TopicsExamples of Important Topics

• Air Pollutants (outdoor, indoor)

• Arsenic• Asbestos

• Hazardous waste sites• Dietary Supplements/

ethnic remediesL d• Asbestos

• Asthma – Environmental risk factors

• Breast Feeding and Food

• Lead• Mercury• Pesticides• PCB’s) and dioxinsContamination

• Carbon Monoxide• Child labor

Endocrine Disruptors

• PCB s) and dioxins• Radiation (Radon,

Ultraviolet light)• Water pollutants

• Endocrine Disruptors• Environmental Disparities• Environmental Tobacco

Smoke

p• Urban design/sprawl• Plastics, BPA, Phthalates


5

S o e

Cumulative riskCumulative riskCumulative riskCumulative risk

Poverty Stressed Poverty

Lead

Stressed mother

Lead

Allergens

Noise

Allergens

Squalid

Poor nutrition

Squalid neighborhood

No parks


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No parks

From Lecture of Dr. Howard Frumkin

Exposure-Disease ModelContaminatedEnvironment

Genetics(potential exposure)

Biological

Biologically Effective Dose

BiologicalUptake(exposure)

TargetO

Biologic

OrganContact

Absorption BiologicChange

Clinical

AbsorptionDistributionMetabolismExcretion


9

DiseaseRepair and physiologic adaptationThreshold

Variations in Susceptibility withVariations in Susceptibility with Developmental Stagesp g

• Preconception• Fetus

• Toddlers (1-2 yrs)• Young Child (2-6)Fetus

• NewbornsI f t

g ( )• School Aged (6-12 )• Adolescents (12-18)• Infants Adolescents (12 18)


10

Neonate and early infancy:Neonate and early infancy: a vulnerable time

• Lack of full development of the blood brain barrier

• Neurons still proliferating• Neurons still proliferating, myelinating, pruning

• Immature immune system• Increased skin surface area andIncreased skin surface area and

absorbs agents more readily• Increased respiratory rate• Dependence on breast milk or p

formula as sole source of nutrition• Unable to move independently


11

Breast FeedingBreast Feedinggg• Diffusion is the primary transport mechanism

• Lipid solubility influence final concentration of a toxin in breast milk

• Liphophilic organochlorine pesticides, PCB’s and PBB’s concentrate in the 30% fat content of breast

ilkmilk

• Lead and methylmercury can also be secreted into b t ilkbreast milk

• ADVANTAGES OF BREASTFEEDING OUTWEIGH RISKS MOST OF THE TIME!


12

RISKS MOST OF THE TIME!

Toddlers and Young ChildrenToddlers and Young Children

• Nearer the ground• Oral exploratory

b h ibehavior• Growth and

development ofdevelopment of lungs

• Dietary deficiencies yand small intestine avidly absorbs lead

Photo: Michigan Lead Safe Partnership


13

Photo: Michigan Lead Safe Partnership

www.bridges4kids.org/lead-general.html

School Aged ChildrenSchool Aged Childrengg• Increased number of environments and

less supervised play.

P t ti l th h h bbi• Potential exposures through hobbies, school crafts, playgrounds


14

AdolescentsAdolescents• Work• Work• Possible Trade

School exposuresSchool exposures• Substance abuse

http://hazel.forest.net/skjold/photo_pages/teen classroom.htm


15

g _

U.S. Department of Labor. Photo by Michael Carpenter

Disparities in Environmental Exposures

Hood, E. (2005). "Dwelling disparities: how poor housing leads to poor health."


16

Hood, E. (2005). Dwelling disparities: how poor housing leads to poor health. Environ Health Perspect 113(5): A310-7

LeadLead


17SOURCE: Meyer PA, et al. Surveillance for elevated blood lead levels among children--United States, 1997-2001. MMWR 2003;52(SS10):1-21.

Air qualityAir quality80

50

60

70

ulat

ion

Whites

20

30

40

Perc

ent p

opu Whites

Blacks

Hispanics

0

10

20P

1 2 3 4

Number of air quality standardsexceeded


18Source: Wernette DR, Nieves LA. Breathing polluted air: minorities are disproportionately exposed. EPA Journal 1992;18:16-17

Asthma and EquityAsthma and EquityAsthma and EquityAsthma and Equity• Asthma prevalence twice as high and• Asthma prevalence twice as high, and

mortality three times as high, in bl k i hitblacks as in whites

• Asthma prevalence 3x higher in Hispanic than non-Hispanic children

• Asthma hospitalization among• Asthma hospitalization among Medicaid children: 93% ↑ in blacks, 34% ↑ in Hispanics compared to


19

34% ↑ in Hispanics, compared to whites

Unhealthy Play Spacesy y p


20Photo by Earl Dotter: Swing Set

Obesity & Physical Activity

• Nationwide shift in physical activity Active teens become active adults– Active teens become active adults

– In 2005, only 35% of HS students met recommended level of physical activityrecommended level of physical activity

• Growth in electronic media– 21% played videogames >3 hours daily121% played videogames >3 hours daily– Average child watches 3 hours TV daily2

– 7.5 hours per day spent with all forms of e-7.5 hours per day spent with all forms of emedia (TV, Internet, chats, games, etc)3


¹CDC. Youth risk behavior surveillance 2005. MMWR 2006;55:SS-5²AAP, Committee Public Ed. Pediatrics 2001;107:423-6³Rideout VJ et al. Kaiser Family Foundation Report. 2010

Obesity & Physical Activity • Growth in electronic media

32% f 2 7 ld & 65% f 8 18 ld– 32% of 2-7 year-olds & 65% of 8-18 year-olds have TVs in bedrooms¹

• Time spent in front of TV or computer = time notTime spent in front of TV or computer time not spent being physically active

• Estimated 25% loss of play time and 50% loss in i t t d td ti it ²in unstructured outdoor activity²

• No Child Left Behind 2001– Increased time for reading and mathg– But at the expense of physical education³

¹ Roberts DF et al. Henry J Kaiser Family Foundation Report, 1999. ² J t FT t l Ch i Ti f A i Y th 1981 2003 U i it f Mi hi


² Juster FT et al. Changing Times of American Youth: 1981-2003. University of Michigan, 2004. ³ Dillon S. Schools cut back subjects to push reading and math. New York Times March 26; 2006.

What is a “safe” level ofWhat is a safe level of exposure for children?


23

Extent of knowledgeg•More than 80,000 chemicals registered with EPA

•Greatest risk are 2,863 high-production-volume (HPV) chemicals (produced inchemicals (produced in amounts of 1 million pounds or more per year)

•Fewer than half have been tested for Toxicity to Human Health•Less than 10% have been tested for pediatric neurotoxicityp y

•Gaps in knowledge are particularly great in regard to d l t l t i it

©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13Grandjean P and Landrigan PJ, Lancet. 2006

developmental toxicity

What is “safe”?What is “safe”?What is safe ?What is safe ?• Levels of what is considered “safe” or• Levels of what is considered safe or

acceptable has changed as new information emerges from recent research

• For lead, research demonstrated sub-clinical effects on cognition and behavior, leading to decrease in the “acceptable level” from blood dec ease e accep ab e e e o b oodleads of 25ug/dL in the late 1970’s, to 10ug/dl, and to present discussions for lowering furtherlowering further

• Research results lead to changes in policy and regulations


25

Leaded PaintLeaded Paint“Don’t Forget the Children” Ad Campaign


26In US leaded paint banned for residential use in 1978

…Lead eventually banned from indoor paint in 1970’s

Effect of Removing Lead From GasolineEffect of Removing Lead From GasolineBlood Lead Levels in USBlood Lead Levels in USBlood Lead Levels in USBlood Lead Levels in US


27

Other areas of question Other areas of question d t dd t dand studyand study

• Autism spectrum and relationship• Autism spectrum and relationship mercury, and/or other environmental

t i tcontaminants

• Plastics: BPA, phthalates, p

• Melamine contaminant-kidney problems

• Mold and damp spaces

• Asthma and environmental factors


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• Asthma and environmental factors

Think Globally, Act LocallyThink Globally, Act Locallyy yy y

Think Future, Act Now


Age distribution of burden of disease Age distribution of burden of disease byby income group 2004income group 2004by by income group, 2004income group, 2004


World Health Organization, 2008

Child l i t ili fChildren play in tailings from Pogera gold mine in Papua, New Guinea, that were found to contain unhealthy levels of ylead, arsenic, cadmium, and other toxic metals

Environmental Health Perspectives 109:A480, 2001

Photo credit: Catherine Coumans


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Photo credit: Catherine Coumans

Village of the Black Teeth: Children with Lead Poisoning


32From: Boston Globe, July 30 2007

Where we are now…


Where do we go from here?Where do we go from here?

• National Children’s Study• National Children s Study– Large longitudinal study to follow children

from conception to 21 years of ageO l t d f it ki d i US Oth– Only study of its kind in US. Other countries have similar studies

– Large budget with poor planning– Currently on hold


34

Where will we be….


Integrating EnvironmentalIntegrating EnvironmentalIntegrating Environmental Integrating Environmental Health into HealthcareHealth into Healthcare

Erica Forrest MS RRT AE CErica Forrest, MS, RRT, AE-CSupervisor, Training and Education

Center for Environmental HealthChildren’s Mercy Hospitaly p


Learning ObjectivesLearning Objectivesg jg j• Identify environmental hazards that exist in a home and

explain what health impacts the hazards may have on occupants

• Determine feasible action steps families can take to reduce environmental hazards in their homes

• Recognize the importance of community resources when dealing with environmental hazards and how to connect families to these resourcesfamilies to these resources


Remain Standing If…Remain Standing If…


Theoretical Propositions of the Theoretical Propositions of the Health Belief ModelHealth Belief ModelHealth Belief ModelHealth Belief Model

Individual Perceptions Modifying Factors Likelihood of Action

Demographic VariablesPsychosocial Variables

Self Efficacy

Perceived Benefits

Perceived

Perceived

Perceived Barriers

Likelihood of taking recommended

preventive health

Perceived Susceptibility

Perceived Severity

Perceived Threat

preventive health action

Severity

C t A ti


Cues to Action

Stages of ChangeStages of Change

Pre- Contemplation“I don’t have a problem”I don t have a problem

ContemplationRelapse Co e p a o“Maybe I have a problem”

e apse“Oops. A slip is not a fall?”

Preparation“I need to make a change”

Maintenance“I’m sustaining my change”

Action“I’m making a change”


I m making a change

NACHC Community HealthCorps Facilitator’s Guide: Health Education

What can providers do?What can providers do?Pre‐contemplation Plant the seeds of doubt. Increase

perception of risk.

Contemplation

Preparation

Educate (reasons to change, risks). Encourage self-efficacy.

Plan the best course of actionPreparation

Action

Plan the best course of action. Anticipate barriers.

Help patient take steps towards change. Action

Maintenance

p p p gContinue to anticipate/address barriers.

Prevent relapse by helping patient identify & i t t t i

Relapse

& use maintenance strategies.

Help patient re-focus on contemplation and planning to start over


and planning to start over.

NACHC Community HealthCorps Facilitator’s Guide: Health Education

Why are Healthy Homes Why are Healthy Homes

Homes can affectImportant to Us?Important to Us?

Homes can affect our health—physically andphysically and mentally

Child dChildren spend as much as 70% of their time inside their homes


time inside their homes

Moisture / Water IntrusionOne defect can lead to multiple

Mold

lead to multiple hazardso d

Asthma Exacerbation


Exacerbation

Structural Damage

Moisture / Water Intrusion


Structural Damage

Pests

Lead Poisoning

Fire

Injuries


PesticidePesticide

Pests

Asthma and Allergy

ExacerbationExacerbation


Pesticide


Structural Damage

Structural Damage

Moisture

MoldMoldMold

Asthma Exacerbation


Components of Asthma ControlComponents of Asthma Control

Stepwise A hApproach

Asthma ControlReduce Impairment


Reduce Risk


Top Asthma Triggersp ggReducing Allergens Improves Asthma Control

Requires Multifaceted Approach, EPR-3


2007 NHLBI Asthma Guidelines2007 NHLBI Asthma Guidelines

• Exposure of patients who have asthma to inhalant ll i it t t hi h th iti hallergens or irritants to which they are sensitive has

been shown to increase asthma symptoms and precipitate asthma exacerbations– Assess sensitivity

• For successful long-term management of asthma it isFor successful long term management of asthma, it is essential to identify and reduce exposures to relevant inhalant allergens and irritants– A multifaceted comprehensive approach is required– A multifaceted, comprehensive approach is required– Single steps to reduce exposure are generally ineffective


National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma.

National Heart, Lung, and Blood Institute, August 2007

2007 Guidelines2007 Guidelines

• Consider multifaceted educational programsConsider multifaceted educational programs delivered in patient’s homes– Multifaceted programs that focus on educating

patients and providing tools to reduce exposure to cockroach, dust-mite, and rodents have demonstrated success in reducing exposures and reducing asthmasuccess in reducing exposures and reducing asthma morbidity.

F th h d d t l t th t– Further research needed to evaluate the cost-effectiveness and feasibility of widespread implementation of such programs will he helpful


Home Assessments Beneficial f M lti l H lth C ditifor Multiple Health Conditions

Mild & Severe Asthma

Elevated Lead Blood

Severe AllergiesAsthma Lead Blood Allergies

Severe Eczema

Cystic Fibrosis

Immuno-compromised

patientsc e a b os s patients


Indicators for an Environmental A tAssessment

S t d ’t dSymptoms don’t respond to “regular” treatment

Symptoms respond to treatment but require it to be continued

• Remain aware of patient compliance with treatment / therapy issues

Unique environmental conditions reported that suggest an assessment is warranted


Role of Primary Care OfficeRole of Primary Care Officeyy

• Help families understandHelp families understand potential environmental hazardshazards

• Focus on those hazards most l t f th f ilrelevant for the family

• Provider offices could serve as a central location for resources


Steps to Healthier HomesSteps to Healthier Homespp

1st Step: Start with people (occupants1st Step: Start with people (occupants know about their health and homes)

2nd Step: Identify/understand potential hazards in the home

3rd Step: Limit sources of contaminants

4th Step: Maintain the home


What to Look for with HousingWhat to Look for with Housing--R l t d Ill ?R l t d Ill ?

• Timing:

Related Illness?Related Illness?

– Do signs and symptoms occur:• At the same time each day? • In the same place each day?• Only in certain times of year?

L ti• Location – Do signs and symptoms go away when out of the

environment?• Corroboration

– Do others have the same signs and symptoms and same timing?


same timing?

Identify Housing Conditions Identify Housing Conditions

W i i d t f

that May Affect Healththat May Affect Health• We may recognize signs and symptoms of

diseases but not the environments that cause ththem:– Many are overlooked

– Many are ignored

• Many exposures are only found because we• Many exposures are only found because we... Ask Questions!


Overlooked Overlooked SourcesSources

• Lead

– Was patient’s home built before 1978? p

• CO (Carbon Monoxide)

G li i th h ?– Gas appliances in the home?

– Attached garage?

– Gas-powered equipment in the home?

CO l i th H ?


• CO alarms in the Home?

Carbon Monoxide AlarmsCarbon Monoxide Alarms

Consumer Product SafetyConsumer Product Safety Commission (CPSC) recommends:

• Place near sleeping areaPlace near sleeping area• Put on every level of a home to provide

extra protection D t i t ll di tl b b id• Do not install directly above or beside fuel-burning appliances or near humid areasCh b tt i t i• Change batteries twice a year

C bi ti k


Combination smoke and CO alarm

Overlooked Overlooked -- “Chalking”“Chalking”gg



Ignored Sources in the Ignored Sources in the HomeHome--C t i tC t i tContaminantsContaminants

ETS (E i t l T b S k )• ETS (Environmental Tobacco Smoke)

– Does anyone in the family smoke?

– Do they want help quitting?

• Consumer Chemicals

– What cleaning chemicals do they use?

Where do they store them?– Where do they store them?

• Pesticides


– Any used? Why?

Keep It Simple Plan –C H lth H P i i l

1. Keep it DRY

Core Healthy Homes Principles

2. Keep it CLEAN

3. Keep it PEST-FREE

4. Keep it VENTILATED

5. Keep it SAFE

6. Keep it CONTAMINANT-FREE

7. Keep it MAINTAINED


http://www.hud.gov/healthyhomes

Keep It Dryp y


Fungi (Molds) & other Fungi (Molds) & other Microbial OrganismsMicrobial Organisms

• WHO report 2009– Association between

dampness and mold anddampness and mold and asthma development

– Due to association between ld d i t / ll imold and respiratory/allergic

disease, controlling dampness and mold highly

d drecommended.


*Indoor Air Quality: Dampness and Mold, World Health Organization, 2009

Most Common Moisture SourcesMost Common Moisture Sources

C d ti hi h• Condensation or high indoor humidity– Bathrooms

Kitchen– Kitchen

– Clothes Dryer


Ways to Control MoistureWays to Control Moistureyy• Fix roof leaks

• Maintain gutters, downspouts, splashblocks

• Make sure water drains away from homey

• Identify/fix plumbing leaks as soon as possiblepossible

• Use exhaust fans in kitchens & bathrooms

• Keep indoor humidity between 30-50%

– Measure humidity with humidity gauges


– Measure humidity with humidity gauges

Asthma Morbidity Associated with yHouse Dust Mite Sensitivity

50

60

30

40Freq wheezeRecent meds

10

20Reg morbidityUrgent visit

0

0

0-2 mm 3-4 mm 5-6 mm >/= 7 mm

Peat et al. Aust NZ J Med 1994;24:270-6

Keep ItKeep It Pest FreePest Free( k h)(cockroach)


CockroachesCockroaches

• More common in multi-unit buildings

• Require moisture/food

• Prefer warm, tight lplaces

• NocturnalSource: University of Nebraskahttp://pested.unl.edu/roachind.htm

• Produce significant allergens


Asthma Morbidity Associated with Asthma Morbidity Associated with C k h A tiC k h A ti

• -/- no allergy/low

Cockroach AntigenCockroach Antigen0 4/ no allergy/low

exposure• -/+ no allergy/high 0.3

0.35

0.4

/ o a e gy/ g exposure

• +/- allergy/low 0.15

0.2

0.25ER visits/yrHsptl/yrgy

exposure• +/+ allergy/high 0

0.05

0.1

exposure -/- -/+ +/- +/+

Rosenstreich, et al. NEJM. 336(19):1356-63, 1997 May 8

Integrated Pest ManagementIntegrated Pest Managementg gg gIntegrated: Using different approaches that work together (for example, cleaning up food spills, sealing up holes underneath cupboards, using baits)

Pest: Cockroaches mice ratsPest: Cockroaches, mice, rats

Management: No more cockroaches,Management: No more cockroaches, mice or rats

©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/1374 74

K It V til t dKeep It Ventilated


Poor Ventilation Affects HealthPoor Ventilation Affects Health• Higher rates of respiratory irritation and

Poor Ventilation Affects HealthPoor Ventilation Affects Healthg p y

illness in housing with poor ventilation– Common colds– Influenza– PneumoniaPneumonia– Bronchitis– Increased asthma episodesIncreased asthma episodes… and increased rates of absence from school or work

©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Version 2.2 76

school or work


Particle ControlParticle Control• Vacuum Regularly

– 12 AMP motor– Bag vs. Bagless?

HEPA Fil– HEPA Filter– Micro-filtration bags for

regular vacuumsregular vacuums– Vacuum Slowly


Furnace and AC Furnace and AC MaintenanceMaintenance

• Use correct size filter

• Change routinely• Change routinely – Every 3 mo. (average) for pleated filters

– Every month (average) for flat filters

• Annual inspection recommended– Professional heating/cooling company


Case Study Case Study ––A li ti fA li ti fApplication of Application of Environmental Health to Environmental Health to

Checklists to gather history

patient Casepatient Case• Checklists to gather history

• Feasible treatment plan-minimizing exposure

• Document environmental education in patient’s medical record

• Follow up if possible


Role of Primary Care OfficeRole of Primary Care Officeo e o a y Ca e O ceo e o a y Ca e O ce• Help families understand potential environmental

hazardshazards– Families can make informed decisions on healthy home

interventions

Focus on hazards that are most relevant for family• Focus on hazards that are most relevant for family– Based on medical history and environmental history– This is where allergy testing is beneficialgy g– Helps family to prioritize and not be overwhelmed

• Provider offices could serve as a central location for resourcesresources– Local to the area such as healthy home grants, minor home

repair, weatherization programs, emergency assistance


Steps to Healthier HomesSteps to Healthier Homespp

1st Step: Start with people (occupants1st Step: Start with people (occupants know about their health and homes)

2nd Step: Identify/understand potential hazards in the home

3rd Step: Limit sources of contaminants

4th Step: Maintain the home


Integrating Healthy Homes into g g yYour Work:

WhatWhat Challenges Does Your

What Strategies Can YouProgram

Face?Can You Share??


Questions and CommentsQuestions and CommentsQuestions and CommentsQuestions and Comments

Erica Forrest2401 Gillham Rd

Kansas City, MO [email protected]@

816-960-8919

www.childrensmercy.org/ceh


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Pediatric Environmental Health - iowapha.org Pediatric EH.pdf · Pediatric Environmental Health Jennifer A Lowry MDJennifer A. Lowry, MD ... Poor nutrition neighborhood No parks 8