AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW...
Transcript of AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW...
![Page 1: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/1.jpg)
AAP ENVIRONMENTAL HEALTH ECHO
(EXTENSION FOR COMMUNITY HEALTHCARE OUTCOMES)
![Page 2: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/2.jpg)
Pesticides & Children: Don’t Try This at home
Catherine Karr MD PhD NW Pediatric Environmental Health Specialty Unit
University of WashingtonPediatrics/Environmental & Occupational Health Sciences
![Page 3: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/3.jpg)
INSECTICIDESPyrethroidsOrganophosphosphatesCarbamatesOrganochlorineManganese compounds
FUMIGANTSAluminium and zinc phosphideMethyl bromideEthylene dibromide
Complexity…. > 1.2 billion pounds of active ingredient > 20,700 products ~ 1000 active ingredients~ 4000 “inerts”
HERBICIDESBipyridylsChlorophenoxyGlyphosateAcetanilidesTriazines
RODENTICIDESWarfarinesIndanodiones
FUNGICIDESThiocarbamatesDithiocarbamatesCupric saltsTiabendazolesTriazolesDicarboximidesDinitrophenolesOrganotincompoundsMiscellaneous
![Page 4: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/4.jpg)
Multiple sources & pathways of exposure
Dietary
Residential Use – indoor/outdoor
Drinking water
School/Daycare – indoor/outdoor
Parks/ neighborhood Rx – lice/scabies
Agricultural Use
Wu X et al. Env Health 2013
![Page 5: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/5.jpg)
Pesticides in US Homes
Northern California Homes with Children
Representative wipe sampling of US households
Stored in the home
Guha N et al EHP 2013. Stout EM et al. Env Sci Tech 2009,
![Page 6: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/6.jpg)
Pesticide concentrations are higher in the child breathing zone after indoor pesticide application
Fenske R et al. Am J Public Health 1990; 80:689-693.
0
100
200
300
400
500
600
<1 4 12 24
Liters/kg/day by age
Air intake
![Page 7: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/7.jpg)
Children ingest more soil and dust (mg/day)
EPA Exposure Handbook 2011
020406080
100120140160180200
Child (mean)Child (95%ile)Adult
![Page 8: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/8.jpg)
Dietary exposures
Age (years) Apple (g/kg/day)
<1 5.0
3-5 3.8
Adolescent/Adult
0.4
Adapted from Selevan 2000, US EPA 2011
![Page 9: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/9.jpg)
Lu C, Toepel K, Irish R, et al. Organic diets significantly lower children’s dietary exposure toorganophosphorus pesticides. Environ Health Perspect 2006;114(2):260–3.
Dietary intervention reduces exposure
![Page 10: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/10.jpg)
The agricultural workplace creates unique sources/pathways
![Page 11: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/11.jpg)
Age & Biomarker Concentrations (Pyrethroids)
![Page 12: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/12.jpg)
NW PEHSU Case
![Page 13: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/13.jpg)
Even in setting of “lower toxicity pesticide”, used per label instructions, symptomatic pesticide-related illness can occur
Identification in clinical practice requires INDEX OF SUSPICION –Environmental History
PEHSUs (along with Poison Centers) are available for guidance on suspect exposures
State & National Biomonitoring infrastructure - valuable resource
Mandated Pesticide Reporting & Programs are highly - valuable resource
Alternative pest control methods are available
Points our case brought home….
![Page 14: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/14.jpg)
Preventing pest problems 1. keeping pests out
and2. getting rid of their food, water and shelterManaging pest problems 1. using non-chemical approaches2. using least-toxic pesticides when necessary and 3. reducing the use of harmful pesticide
IPM ResourcesUC IPM onlineEPA Controlling pests
Safer approaches to Pest Control:Integrated Pest Management
![Page 15: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/15.jpg)
Magnitude of the Problem?
Reports 2006-2010
≤ 5 years 6-19 years ≥20 years
Insecticides 69,696 29,509 107,635
Rodenticides 60,209 2,633 6,929
Misc.pesticide 20,161 835 2,387
Herbicide 11,592 3,225 18,715
Fungicide 1,199 433 3,044
Fumigant 215 196 950
Langley RL, Mort SA. Human Exposures to Pesticides in the UnitedStates, Journal of Agromedicine. 2012; 17:300-315.
No national surveillance, no “rates”
Poison Center Data
2006-2008Age 0-17 years2497 ED visits470 Hosp.
![Page 16: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/16.jpg)
Acute Poisoning
Underreporting
80% of children with organophosphate poisoning were transferred with the wrong diagnosis….
Lack of training12% of Pediatric Residencies include Pesticides
70% of clinicians treating children at farmworker clinics had no training re: pesticides & children
Zweiner RJ, et al. Pediatrics 1988, Sofer S. Ped emerg. Care 1989, Roberts JR. Am Peds 2003, Karr C. J Agromed2006.
![Page 17: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/17.jpg)
Chronic low dose effects
Mechanisms ≠ acute toxicity mechanisms
Epidemiological associations with major chronic morbidities of childhood:
Neurocognitive/neurobehavioral deficit and disorder (reduced IQ, inattention/ADHD, Autism, Learning disability)Pediatric cancer (Leukemia, brain)Birth outcomes (premature birth, fetal growth, congenital anomalies)
Other – asthma, diabetes
Roberts JR, Karr CJ; Council on Environmental Health. American Academy of Pediatrics. Pesticide exposure in children. Technical Report. Pediatrics. 2012;130(6): e1765 -e1788
![Page 18: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/18.jpg)
Pediatric Chronic exposure & Disease/DisabilityBottom Line Summary (AAP Technical Report 2012)
Animal models + well designed cohort studies demonstrate insecticide (OP) exposures that are being experienced by U.S. children/pregnant women may have adverse neurodevelopmental consequences
More limited data on pyrethroids raise similar concerns
Many pediatric cancer studies suggestive but limited exposure characterization
Need for more robust studies and characterization of associations of pesticides with birth outcomes, endocrine disruption, asthma
Roberts 2012, Wagner Schuman 2015, Viel 2017
![Page 19: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/19.jpg)
Glyphosate of increasing interestGroup 2A (Probably Human Carcinogen)
Glyphosate is the most commonly used herbicide in the world
![Page 20: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/20.jpg)
Glyphosate: Pediatric health concerns?
• Toxicological studies demonstrate potential for oxidative stress, hepatotoxic and/or endocrine disrupting effects at doses far below RfD
• Several studies have also suggested that in uteroexposures to glyphosate and its formulations can have reproductive effects and can adversely impact developing fetuses
• A study in Minnesota’s Red River Valley found that children with ADHD were 3.6-times more likely to have been born to glyphosate-exposed pesticide applicators
![Page 21: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/21.jpg)
BRING THIS HOME
Concerning exposures occur but are preventable
Acute illness/toxicity in children will present to pediatric care providers
Requires an “Index of suspicion” and Environmental Hxtaking
Subclinical, cumulative low dose exposures are increasing linked with important pediatric morbidities, particularly neurocognitionand neurobehavioral development
Pediatricians are a trusted/influential voice on safe practices, prevention behaviors and policies
![Page 22: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/22.jpg)
Anticipatory Guidance for Patients
Reduce Pesticide exposure In /Around the Home Use low toxicity or non toxic pest control approaches for home/garden pest problems. Reduce Take Home from Work Exposure If work with pesticides, takes steps to reduce “take home” exposure Reduce Exposure From Food Purchase organic when possible, but not at the expense of a diet rich in a variety of fresh fruits and vegetables. Wash and scrub produce with water (cleansers not necessary), throw away the outer leaves of leafy vegetables
NW PEHSU Factsheet on Pesticides for Health Care Providers
![Page 23: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/23.jpg)
http://www.ewg.org/foodnews/guide/
![Page 24: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/24.jpg)
ResourcesTalk to a humanAcute poisoning concerns/acute management – the Poison CenterChronic health concerns/other - PEHSU
Web Based ResourcesEPA’s Handbook “Recognition and Management of Pesticide Poisonings” 6th edition, available online
AAP Council on Environmental Health Technical Report and Policy Statement – Pesticide Exposure in Children (Pediatrics 2012;130;e1765)
eLearning modules (pehsu.net)Pesticides and Child Health: Exposure Recognition and PreventionPesticides Residues in the Indoor Environment
BooksAmerican Academy of Pediatrics. Handbook of Pediatric Environmental Health (3rdedition). For purchase as shelf book or e book
IPM ResourcesUC IPM onlineEPA Controlling pests
![Page 26: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/26.jpg)
This material is supported by the American College of Medical Toxicology (ACMT) and funded (in part) by the cooperative agreement FAIN: U61TS000238-04 from the Agency for Toxic Substances and Disease Registry (ATSDR).
Acknowledgement: The U.S. Environmental Protection Agency (EPA) supports the PEHSU by providing partial funding to ATSDR under Inter-Agency Agreement number DW-75-95877701-4. Neither EPA nor ATSDR endorse the purchase of any commercial products or services mentioned in PEHSU publications
Disclaimer and acknowledgements
![Page 27: AAP ENVIRONMENTAL HEALTH ECHOMar 27, 2018 · Don’t Try This at home. Catherine Karr MD PhD . NW Pediatric Environmental Health Specialty Unit. University of Washington. Pediatrics/Environmental](https://reader036.fdocuments.in/reader036/viewer/2022071414/610e51a6c5902a51334d68de/html5/thumbnails/27.jpg)
www.pehsu.net/nationalclassroom.html
Webinars
Series of scientific webinars that provide a forum for discourse on scientific
issues.
Live and On-Demand
Case Conferences Journal ClubsGrand Rounds
CE Available
Online Courses
Interactive and Self-Paced
Evidence-based online courses on a variety of
children's environmental health topics.
CE Available
Resource Catalog
Fact sheets, journal publications, reports, and
other resources for parents, community members,
patients and healthcare professionals
Topics included: Air Quality, Pesticides, Natural
Disasters, BPA, Mold, Lead, Mercury