1 / 45

The Pediatric Environmental Health Toolkit Training Program for Health Care Providers 2006/2007

The Pediatric Environmental Health Toolkit Training Program for Health Care Providers 2006/2007. What We Will Cover. Background on pediatricians’ current practices related to environmental health The unique vulnerabilities of children The development of the Pediatric Toolkit

sook
Télécharger la présentation

The Pediatric Environmental Health Toolkit Training Program for Health Care Providers 2006/2007

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The Pediatric Environmental Health Toolkit Training Program for Health Care Providers2006/2007 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  2. What We Will Cover • Background on pediatricians’ current practices related to environmental health • The unique vulnerabilities of children • The development of the Pediatric Toolkit • Case studies on environmental exposures • How to use the Toolkit to address these issues Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  3. Parental Concern vs. Pediatrician Advice Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Stickler GB, Simmons PS., Clin Pediatr 1995

  4. The Environmental History in Pediatric Practice: A Study of Pediatricians’Attitudes, Beliefs, and Practices • Fewer than 20% report training in environmental history taking. • Strongly believe in importance of environmental exposures to children’s health. (53.5% had patient seriously affected) • Lack confidence in environmental history-taking, and in discussing environmental exposures with patients. • Preferred resources: AAP patient education materials, newsletters Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Kilpatrick N et al., EHP 2002

  5. The Chemical Environment • > 82,000 synthetic chemicals on EPA inventory of chemicals manufactured in U.S. today • Most first synthesized • in the past 50 years • ~ 700 new chemicals introduced each year • Few chemicals tested for basic toxicity Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit GAO-05-458. 2005

  6. Chemicals Covered in Case Examples Metals including Arsenic, Mercury and Lead Pesticides Persistent Organic Pollutants (POPs) (Example – PCBs) Second Hand Smoke (SHS) Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  7. Exploratory behavior Crawling Hand to mouth activity Restricted diet Teens – work, hobbies, high risk behaviors Still growing and developing Absorption, metabolism, & elimination different Blood-brain barrier still forming in young infants Unique Susceptibilities of Children Children differ physiologically: Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  8. Increased Exposure from Inhalation and Dermal Absorption • Increased metabolic rate • Higher minute ventilation • Newborn 400 ml/min/kg • Adult 150 ml/min/kg • Roughly double the surface area to body wt. • Increased absorption from dermal route Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Miller M et al., Intl J Tox 2002

  9. Mean Water Intake Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Miller M et al., Intl J.Tox 2002

  10. The Pediatric Environmental Health Toolkit Developed to enable pediatric and family care providers to routinely include, in well-child visits, information on preventing toxic exposures. The “Toolkit” includes visually exciting and creative materials that have been designed for easy use by practitioners. Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  11. Toolkit Development in Brief • Demand for concise materials – Green Book • “Cliff Notes” • Developed by PSR, local American Academy of Pediatrics (AAP) chapters (Northern CA and MA), University of California San Francisco Pediatric Environmental Health Specialty Unity (UCSF PEHSU) • Pilot tested in CA and MA • Training Programs in 5 States funded by the EPA • Endorsed by the AAP Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  12. Toolkit Provider Materials Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  13. Toolkit Patient Materials Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  14. Case 1 – Transient Hypertonia in an Infant • 7lbs. 14 oz. term female, jaundice peak bili 12.6 • Nl. PE at 12 weeks except lower extremity hypertonicity • Pediatric consult at 16 weeks - upper and lower extremity hypertonicity, ankle clonus with Dx of cerebral palsy • Physical therapy begun • No environmental hx was taken Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Wagner SL, Orwick DL., Pediatrics 1994

  15. Case 1 continuedTransient 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 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Wagner SL, Orwick DL., Pediatrics 1994

  16. Anticipatory Guidance Card Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  17. Urban Exposure to Pesticides During Pregnancy Ubiquitous • NYC women wore backpack air samplers for 48 hrs during 3rd trimester • 266/314 report pest measures at home (90% for cockroach) • ALL testing positive for exposure to at least 4 pesticides • Cord blood levels = maternal • Chlorpyrifos associated with decrease BW and length Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Whyatt et al. Envir. Health Persp. 2002

  18. Pesticides and Children Associations noted with: • Leukemia • Non-Hodgkin’s lymphoma • Soft tissue sarcoma • Brain tumors • Same tumors repeatedly found in adult studies. • Also associations with: • Neurodegenerative disorders – Parkinson's Disease • Birth defects • Neurodevelopmental disorders Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Zahm SH, Ward MH., EHP 1998

  19. Indoor ResiduesAfter Outdoor Pesticide Application Pre-Application - 1.94 mcg/d Post-Application – 8.87mcg/d Two Weeks After Application 2,4-D pesticide tracked in by family dog and home owner (applicator) Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Nishioka MG et al. EHP 2001

  20. 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 chlorpyrifos and malathion • Again elevated on re-introduction of conventional diet Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Lu C, Toepel K, Irish R, Fenske RA, Barr DB, Bravo R, EHP. 2006

  21. Advice for Buying Organic Pesticide Report Card Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Environmental Working Group www.ewg.org

  22. Case 3 -Family with Unexplained Symptoms • Family (all 8 members/2 children) develops recurring neurologic and medical illness over four years, worse in winter • Fatigue, rashes, seasonal alopecia • Recurrent sever respiratory infections • Debilitating headaches, malaise • Severe recurrent nosebleeds • Both children have “grand mal” seizures and hyperesthesia • Fish and houseplants have died Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Peters HA, Croft WA, Woolson EA, Darcey BA, Olson MA., JAMA 1984

  23. 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 Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  24. Case 3 – continuedUnexplained Symptoms • Family used recycled “old” wood in their stove • Chromated Copper Arsenate (CCA) treated wood • Stove ashes with > 1,000 ppm arsenic contaminated living area • CCA – commonly used wood preservative (decks, playground equipment etc.) No longer produced for residential use. • Arsenic – anti-metabolite, interferes with ATP cycle. Known human carcinogen Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Kwon E. et al EHP 2004

  25. Advice for Patients & Providers Topic Health Effects SummarySources and Prevention Strategies Routes of Exposure Arsenic Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  26. Case 4 -Patient Concerned About Fish Consumption • 3½ y/o male with a diagnosis of developmental/behavioral disorder at age 3 • Otherwise healthy except for eczema • Normal birth Hx • Exclusively breastfed for 3 months, then transitioned to formula • Mother ate 1- 2 tuna steaks per week during 3rd trimester and while breastfeeding • Relationship to development, testing, treatment? Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  27. Mercury: Health Effects Prenatal Exposure • Higher Dose Mental retardation, seizures, disturbances of vision, hearing, motor control Lower Dose Impairments in attention, memory, and language Delayed conduction on BAER Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  28. Tuna Mercury Concentrations* Mean - 0.38 ug/g Maximum - 1.3 ug/g  Patient weight ~ 70 kg Serving size (tuna steak) ~ 8 ozs (227 grams) Dose Calculation (average)  0.38 ug/g x 227g x 1.5 servings / 70 kg wt. x 7 days = 0.26 ug/kg-day  (high-end 0.9 ug/kg-day) Both exceed EPA reference dose 0.1 ug/kg-day  *FDA data from 2004 Mercury Dose Calculation for Concerned Patient Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  29. CDC data show approximately 5.7-8% of US women of childbearing age exceed EPA defined safe exposure limit Government agencies provide guidance on mercury in fish States provide guidance on freshwater fish consumption guidelines Population Exposures are Significant – Government has Taken Action Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  30. How Much Fish is Safe? IATP Fish Calculator • 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. Enter your body weight in pounds: Select the species of fish you eat: Get your Results! www.iatp.org Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  31. Benefits of Maternal Fish Consumption Lessened by Mercury Exposure • Fish is a good food source: • Source of protein, iron, vitamin E, selenium, and long chain n-3 polyunsaturated fatty acids • Higher fish consumption associated with improved infant cognition • However...Higher mercury (even very low dose) associated with reduced cognition • Suggests eating fish with less mercury Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Oken E et al., EHP 2005

  32. Case 5 - Occupational/Take Home Exposures • A day laborer goes to the ER for a work related injury. • He is working on demolishing a firing range so a lead level is obtained and is 74 mcg/dl after 3 days on this job. • Four other workers tested between 57 and 98 (all worked less than 2 ½ weeks). • What should be done? None had previously worked with lead. Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit Hipkins KL, Materna BL, Payne SF, Kirsch LC., Clin Pediatri 2004

  33. Case 5 - continued Occupational/Take Home Exposures • 9 children of three workers tested between 13 and 34 mcg/dl. (highest 18 month old) • Wife of one with symptoms and Pb level of 36 mcg/dl. • Workers may bring home hazards on clothing, shoes, and body. • In 2001-2002 year, 22% of California childhood lead poisoning cases had potential contribution from occupational sources. Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  34. KEY CONCEPTS Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  35. Case 6 –Exposure but no Symptoms • Father concerned that for past seven months oily residue found on driveway/car • Children play in that area • Finally determined coming from power transformer just off property • Is there potential danger? • Power company contacted and said nothing to worry about Know Your Resources: ATSDR, EPA regional office, PEHSU, state offices, AOEC Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  36. PCB Exposure In Utero • Health Effects: • Decrease in full scale and verbal IQ at 11 years old • Decrease in word and reading comprehension • Decrease in memory and attention Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  37. Breastfeeding is Best for Baby Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  38. Second Hand Smoke (SHS) Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  39. Effects Causally Associated w/ SHS Exposure • Developmental Effects • Fetal Growth: LBW and decreased birthweight • Sudden Infant Death Syndrome • Respiratory Effects • Acute lower RTIs in children • Asthma induction and exacerbation-children/adults • Chronic respiratory symptoms in children • Eye and nasal irritation in adults • Middle ear infections in children • Carcinogenic Effects • Lung Cancer, Nasal Sinus Cancer • Breast Cancer • Cardiovascular Effects • Heart disease mortality and morbidity Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit CAL EPA 2005

  40. SHS & Breast Cancer - Premenopausal Women • 14 Studies Reviewed - 13 found an Increase in Risk (7 statistically significant) • 70% Increase in Breast Cancer Risk • Windows of susceptibility during rapid proliferation Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit CAL EPA 2005

  41. Smoking Hazards Addressed at Various Life Stages Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  42. Summary • The body of scientific evidence continues to build regarding the impact of environmental toxicants on children’s health • A precautionary approach that emphasizes prevention is good patient and public health • Guidance on preventing exposures to children and families can be incorporated by pediatric providers into well child visits using the Pediatric Environmental Health Toolkit • Society needs to work on “upstream” prevention issues beyond the clinical setting Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  43. Acknowledgements • Primary Author: • Mark Miller MD MPH • Contributing Authors/Reviewers: • Michelle Gottlieb MEM, Guenter Hofstadler MD, Brian Linde MD, Siobhan McNally MD, • Marybeth Palmigiano MPH, Kathy Shea MD, • Gina Solomon MD MPH, Maria Valenti, • David Wallinga MD MPA Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  44. Planning and Development Physician Group California Lisa Asta MD FAAP - Chair, Department of Pediatrics, John Muir Medical Center Guenter Hofstadler MD MPH FAAP - Pediatrician, Contra Costa Regional Medical Center Brian Linde MD FAAP - Pediatric Hospital Based Specialist, Kaiser Permanente, Oakland, California Mark Miller MD MPH FAAP - Pediatrician and Director, UCSF Pediatric Environmental Health Specialty Unit Massachusetts Siobhan McNally MD FAAP - Berkshire Medical Center and the University of Massachusetts Medical School Minnesota David Wallinga MD MPA - Senior Scientist and Antibiotic Resistance Project Director, Institute for Agriculture and Trade Policy Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

  45. For More Information Greater Boston Physicians for Social Responsibility 617- 497-7440 - www.igc.org/psr Pediatric Environmental Health Toolkit 2006 Greater Boston and San Francisco Bay Area Physicians for Social Responsibility, UCSF Pediatric Environmental Health Specialty Unit

More Related