Child health & environment

19 APR 07 Dr. M. S. Prasad 1

EnvironmentEnvironment&&

Child Health Child Health

Dr. M. S. PrasadDr. M. S. PrasadConsultant & HeadDept. of Paediatrics

Safdarjung Hospital &Vardhaman Mahavir Medical College

New Delhi


Environmental Hazards and Environmental 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: Committee Committee 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..


EnvironmentEnvironmentEnvironmentEnvironmentThe term environment implies all The term environment implies all the external factors – living and the 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 all The term environment implies all the external factors – living and the 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 ADULTS CHILDREN 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-feedingPollutants 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

NewbornToddlerChildAdult

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 environment A 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


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 Indoor HazardsHazards..


SICK BUILDING SYNDROMESICK BUILDING SYNDROMEWhat 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


MOULDMOULDOccurs in damp Occurs 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.

http://en.wikipedia.org/wiki/Hurricane_Katrina

http://upload.wikimedia.org/wikipedia/commons/3/3f/DublinMold.jpg


http://upload.wikimedia.org/wikipedia/commons/6/6e/Moldy_nectarines.jpg


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 on Diagram 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 incompleteEPA


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 that It is recommended that homes be tested for radon homes 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 radonLevels 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


LeadLeadLeadLead


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 potterySigns 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 EnvironmentWorld 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 Organic Persistent Organic

Pollutants (POPs) & Pollutants (POPs) & Endocrine Disruptors.Endocrine Disruptors.

Children's Health and the EnvironmentWorld Health Organization

www.who.int/cehAugust 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

AldrinDieldrin

ChlordaneDDT

Endrin Heptachlor

MirexToxaphene

INDUSTRIAL CHEMICALS

PCBsHCB

UNINTENDED BY-PRODUCTS

DibenzodioxinsDibenzofurans

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: HexachlorobenzeneWhite 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

WhaleSeals

OTHER

VegetablesCerealsFruits

ANIMALFAT

MeatPoultry

COW'SMILK

ButterDairy products

FISH

SalmonEel

ShellfishFish liverFish 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

PorphyriaIARC 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.


Paediatric Paediatric Environmental Environmental

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

"A g

reen p

age in

the clin

ical record

"






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?

HobbiesPainting – paint and solvents?Model-building – glue and solvents? Pottery – pigments, paints?Gardening – pesticides?Woodwork – chemicals?

ActivitiesEating habits (type of diet, food quality)Drinking habits (alcohol use and abuse, soft drinks)Playing habitsLearning habitsWorking habitsScavenging (time spent near garbage)ExploringTesting (trying drugs, eating unknown berries)

SportsType of sportSports area InjuriesToxic exposuresUse of energizing drugsApplication 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 cosmeticsCultural practicesReligious practicesTraditions 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

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

Healthcare

Child health & environment