Pediatric Environmental Health Global Situation
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Pediatric Environmental Health Global
Situationศ.พญ.สุ�วรรณา เร�องกาญจนเศรษฐ์�
อ.พญ. ร�ชน�วรรณ สุ�น�ทธ์�ก�ลคณะแพทยศาสุตร� โรงพยาบาล
รามาธ์�บดี� มหาว�ทยาล�ยมห�ดีล
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Should We Be Concerned?
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Data from CDC / National Center for Health Statistics
Increase in Diabetes (1980-2010)
Increase in Autism Prevalence
Increase in ADHD
Increase in Asthma
Should We Be Concerned?
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Cancers Birth defects (cleft palate,
cardiac malformations) Reproductive dysfunction
(infertility) Lung dysfunction (asthma,
asbestosis) Neurodegenerative diseases
(Parkinson’s) Neurodevelopmental
disorders (autism) Cardiovascular disease (air
pollution, dioxins) Endocrine disorders (diabetes)
Diseases with a Known or Suspected Environmental Component Include:
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“ENVIRONMENT” Includes:
Industrial chemicals
Agricultural chemicals
Physical agents
(heat, radiation)
By-products of combustion and industrial processes (dioxin)
Foods and nutrients
Prescription drugs
Lifestyle choices and substance abuse
Social and economic factors
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Climate change and weather effects
Trends in global surface temperature, sea level, and northern hemispheric snow cover over the last 150 years.
(Reproduced from Pachauri RK, Reisinger A, editors: Climate Change 2007 : Synthesis Report)
• พาย�ไซโคลน
• Extreme Heat Event - Heat Stroke - Palm + MI - ใช) A/C => Pollution Asthma + COPD• พ�ช => ขาดีอาหาร => Migration
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Climate change and weather effects
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• Complete loss or displacement of Succulent Karoo biome projected under climate change, and many species losses in other biomes
• Intensity of extreme events increased significantly over South Africa; biome shifts will favor horticulture over plantation forestry; malaria risk areas projected to expand southward
• Floods in 1999 severely affected coastal population and infrastructure, with long – lasting economic and development impacts; adaptation and recovery very costly and beyond the means of African countries
• East African Great Lakes and reservoirs respond to climate variability with pronounced changes in storage
• Long – lasting impacts of drought on national economics for the Southern African Development Community region
• Coastal marine fisheries likely to be negatively affected by changes in Bangwuela current
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Climate Change and Weather Effects1.
Infection2. Ozone depletion 3. Loss of Biodiversity 4. Environmental Endocrine Disruptor (EED)
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Climate Change and Weather Effects1.
Infection• Infection & their vector - Mosquito – Breeding นานข+,น - Malaria, Dengue, Encephalitis• Public Health Condition favoring disease
2. Ozone depletion
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CFC , UVB => Ocular & Dermatologic effect
=> Immune system• UVB - photoimmunity => Immune
- association – pulm TB เพ�-ม vinalence & rapid - smallpox , Herpes
simplex & papilloma - ร�กษาดี)วย UVB –
psoriasis แล)วดี�ข+,น
Ozone depletion
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Climate Change and Weather Effects1.
Infection2. Ozone Depletion3. Loss of Biodiversity
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Climate Change and Weather Effects1.
Infection2. Ozone Depletion 3. Loss of Biodiversity • Water
pollution• Air pollution• Soil pollution
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Loss of biodiversityWater Pollution Fecal contamination -> waterborne gastroenteritis
Cholera, Dysscentery, Typhoid, Trachoma
Virus - gastroenteritis - HAV - Polio
Parasite - Protozoa - Helminths -
Schislosome - Others - Sarcoptes scabie, Ringworm Natural Toxin - Arsenicosis
- Fluorosis - Lead - Organic ; Benzene
, Toluene - Inorganic ;
Arsenic , Copper
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Air Pollution• PM 10 : penetrate เข)าปอดี• So2 and No2
• Ground Ozone - No2 or VOC => inflammation of lung tissue
exacerbate asthma & chronic lung - ผิ�วหน�ง => itching & swelling systemic => immune system• Allergens – asthma
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Soil Pollution• Pesticides - Acute Organochlorine – Persistent Organic Pollutant (POPs) Organophosphate poisoning
- Chronic birth defect (cleft palate, musculoskeletal, CNS), neuro problem ( Memory & Parkinson), skin, DM and CA (non – Hodgkin lymphoma, leukemia, sarcoma, prostate CA, MM) infertility - Sewage & Rotting organic materials
DDT (Dichlorodiphenyl trichloroethane) เป0น EED - affect developmental and reproductive health
- genetic disruption risk to cancer & DM
Soil Pollution
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Climate Change and Weather Effects1.
Infection2. Ozone depletion 3. Loss of Biodiversity 4. Environmental Endocrine Disruptor (EED)
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Environmental Endocrine Disruptor (EED)
Chemicals that in vitro possess an
ability to act on
the endocrinologic system (children are
more
susceptible than adults) eg. herbicides,
fungicides,
plasticizers
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EED great concern in children
Bisphenol A : weak estrogen found in many
plastics
Phthalates : an agent commonly used in
plastics with suspected spermatotoxic effects
PCB : can affect the duration of lactation and
menache
Arsenic – toxic to adrenal cortex
Perchlorates
Dioxin
PDBE
Toxic to thyroid
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Pediatric environmental health is a relatively new discipline that examines the effects of environmental agents on the health of children.
Children have greater risk of exposure to environmental agents, as well as greater susceptibility to toxic effects, than adults.
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A number of environmental pollutants are more likely to produce clinical toxicity in children than in adults. These include lead, mercury and polychlorinated biphenyls.
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Overview of Children’s development features that can affect
Toxicokinetics
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Environmental Toxins relevant to children’s healthAir particulates Mercury
Arsenic Ozone
Asbestos Perchlorates
Carbon monoxide Pesticides
Environmental tobacco smoke (ETS)
Polybrominated dipheyl ethers (PDBE)
Indoor air pollutants
Polybrominated biphenyls (PCBs)
Lead Radon
M-tert-butyl ether (MTBE)
TrichloroethyleneHaddad and Winchester’s Clinical Management of Poisoning and Drug overdose, 2007
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The dose-response curve of potential toxins, including drugs, chemicals, and physical agents, can have threshold deterministic and stochastic effects
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Redrawn from WHO World Health Report, 2002.©WHO 2005
Deaths from indoor smoke from Solid fuels
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Photo courtesy of Dr. Molly Kile , Harvard School of Public health
Hyperkeratotic rash of arsenic intoxication
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Photo courtesy of Dr. Molly Kile , Harvard School of Public health
Hyperkeratotic rash of arsenic intoxication
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Pediatric Considerations - Lead
Children absorb lead more
efficiently than adults
Children who are malnourished
are particularly susceptible to
lead due to lower intakes of
iron and calcium which can
reduce the absorption of lead
Blood lead levels > 10 g /dL
among children are considered
elevated, but no level is
considered safe
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Health Effects Associated with Fibrogenic and Metal Dusts
Asbestos Silica Cotton Dust Coal Dust
Metals Lead Manganese Chromium Beryllium Mercury
(inorganic)
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Health Effects Associated with Fibrogenic and Metal Dusts
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Adverse Health Effects Caused by Selected Classes of Pesticide*
Insecticide Borates Carbamates Organochlorines Organophosphates
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Adverse Health Effects Caused by Selected Classes of Pesticide*
Insecticide
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Adverse Health Effects Caused by Selected Classes of Pesticide*
Rodenticide Coumarins Fluoroacetate Metal phosphides Strychnine Thallium
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Adverse Health Effects Caused by Selected Classes of Pesticide*
Rodenticide
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Adverse Health Effects Caused by Selected Classes of Pesticide*
Herbicides Dipyridil Phosphonates Triazines
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Adverse Health Effects Caused by Selected Classes of Pesticide*
Herbicides
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Adverse Health Effects Caused by Selected Classes of Pesticide*
Fungicide Mercury, organic Halocarbons (fumigant)
Organotin Phenol derivatives (fungicide, wood preservative)
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Adverse Health Effects Caused by Selected Classes of Pesticide*
Fungicide
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Others Arsenicals Chloralose Diethyltoluamide (insect repellent)
Adverse Health Effects Caused by Selected Classes of Pesticide*
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Others
Adverse Health Effects Caused by Selected Classes of Pesticide*
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Pediatric Consideration -
Pesticides Approximately 70% of working children work in agriculture and may be exposed to pesticides at occupational levels worldwide.
Children are particularly vulnerable to the effects of pesticides because they have lower levels of enzymes involved in the metabolism and excretion of pesticides such as organophosphates.
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Pediatric Consideration
Children may be more likely to be exposed to some contaminants and toxins due to hand-to-mouth activity
For a given exposure, children have greater exposures per unit of body weight
Children less efficiently metabolize and excrete many toxic chemicals
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Mold / Food Impurities Aflatoxin Ergotism Farmer’s lung disease Melamine
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Outlines What is environmental pediatric?
Hazards specific to children
Toxic effects of selected manufactured chemicals
Air quality Anticipatory guidance
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“Health and disease in children and that diagnoses, treats, and prevents diseases
and disabilities caused in children by environmental
exposures.”
What is environmental
pediatrics?
Landrigan PJ, Miodovnik A.Mt Sinai J Med. 2011 Jan-Feb;78(1):1-10.
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Many Endpoints / Outcomes Cancer and birth defects are
not the only endpoints Complex diseases have
complex causes Obesity, diabetes,
cardiopulmonarydisease, cancer, autoimmune disease, neurodevelopmental disorders, schizophrenia,addition, depression are some diseases where the environment acts through epigenetic mechanisms.
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OLD… chemicals act by overwhelming the body’s defenses by brute force at very high dosesNEW… chemicals can act like hormones and drugs to disrupt the control of development and function at very low doses to which the average person is exposedNEW… susceptibility to disease persists long after exposure (epigenetics)
Conceptual Shift for Environmental Health Sciences
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Windows of Susceptibility
Development is sensitive time for exposureoRapid GrowthoActive and extensive cell
differentiation oIncreased metabolic rateoDeveloping immune system oOpportunities for initiation of
lesions and promotion of altered cells
oDevelopment is a highly integrated process
oProgramming (epigenetic marks set)
Adolescence also sensitive time for development
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Greater exposures than adults to toxic chemicals on a body-weight basis
Metabolic pathways are immature
Incredibly rapid, but exquisitely delicate developmental processes are easily disrupted
More time than adults to develop chronic diseases that may be triggered by harmful exposures in the environment
Behavior and development
Adolescence also sensitive time for development
Landrigan PJ, Miodovnik A.Mt Sinai J Med. 2011 Jan-Feb;78(1):1-10.
Windows of Susceptibility
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Early Prenatal Mid-Late
Prenatal Postnatal
Week 1-16 Week 17-
40 Birth –25
years
Central nervous system (3wks - 20 years)
Ear (4-20 wks)
Kidneys (4-40 wks)Heart (3-8)
Immune system (8-40 wks; competence & memory birth-10yrs)
Limbs (4-
8wks)
Lungs (3-40 wks; alveoli birth-10yrs)Reproductive system (7-40wks; maturation in
puberty)
Skeleton (1-12 wks)
Source: Altshuler, K; Berg, M et al. Critical Periods in Development, OCHP Paper Series on Children's Health and the Environment, February 2003.
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Gestation Childhood Reproductive Life Middle Life Later LifePuberty
Environmental Exposures
Developmental Origins of Disease:
Developmental Stressors Lead to Disease Throughout
Life
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Dev
elo
pm
enta
l E
xpo
sure
s
AGE 2 12 25 40 60 70
Learning Differences/Behavior
AsthmaIncreased Sensitivity
to InfectionsTesticular Dysgenesis
Syndrome
Obesity
Altered Puberty
Infertility
FibroidsPremature Menopause
Breast Cancer
AtherosclerosisCardiovascular
Disease
Prostate Cancer
Alzheimer's
Parkinson's
Examples of Developmental Origins ofHealth and Disease (DOHAD)
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The study of changes in DNA expression that are independent of the DNA sequence.
A person’s DNA base sequence doesn’t change, but expression of DNA is affected by changes in DNA “packaging.”
Environment is critical factor in DNA expression; we’re born with genes, but environment affects epigenetic changes.
Epigenetics
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DISEASE
EPIGENOME
Adverse health outcomes
CancerCardiopulmonary
diseaseAutoimmune disease
ObesityDiabetes
Neurodevelopmental disorders
SchizophreniaAddiction
Depression
Epigenetic Changes Have Been Implicated in
a Wide Variety of Human Diseases
Normal processesDevelopment
Cell differentiation Aging
GENOME
External influencesEnvironmental
exposures Nutrition
Chemical toxins Metals
Mediators of stress Drugs of abuse
Infection (including HIV)
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Effects of selected chemical pollutants on infants and
childrenCHEMICAL
POLLUTANTEFFECT(S)
DiethylstilbestrolAdenocarcinoma of the vagina after intrauterine exposure
ThalidomidePhocomelia after intrauterine exposure
TrichloroethyleneElevated risk of leukemia after intrauterine exposure
AlcoholFetal alcohol syndrome after intrauterine exposure
LeadNeurobehavioral toxicity from low-dose exposure
Nitrosamine, vinyl chloride, ionizing radiation
Increased risk of cancer after intrauterine exposure
Organophosphate insecticides
Developmental neurotoxicity
Nelson, Ed 19th
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Lead Child labor Pesticides Persistent organic pollutants (POPs)
Fluoride Endocrine disruptors: POPs, arsenic
Hazards specific to children
Guidotti TL, Gitterman BA. Pediatr Clin North Am. 2007 Apr;54(2):335-50
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Prenatal exposure to organophosphate (OP) pesticides can lower a
child’s IQ
67
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Pesticides Herbicides, insecticides,
fungicides, rodenticides Used to prevent, destroy, repel,
or mitigate pests (insects, microbe, animals) or unwanted plants
Found in air, soil and water
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Pesticides
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Recent NIEHS Studies on Pesticide Effects
• High Pesticide Exposure Events (HPEE) & Cognitive Decline
- One or more HPEE may contribute to adverse CNS outcomes independent of diagnosed pesticide poisoning.
- Findings part of Agricultural Health Study.
• Two Pesticides Associated with Parkinson’s Disease
- People who used either rotenone or paraquat developed Parkinson's disease approximately 2.5 times more often than non-users.
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Lead Child labor Pesticides Persistent organic pollutants (POPs)
Fluoride Endocrine disruptors: POPs, arsenic
Hazards specific to children
Guidotti TL, Gitterman BA. Pediatr Clin North Am. 2007 Apr;54(2):335-50
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Persistent organic pollutants (POPs)
Halogenated, carbon-based chemicals
Resist the natural mechanisms of catabolism in the environment
Organochorine pesticides: toxaphene, chlordane, DDT, mirex, aldrin, dieldrin
Polychlorinated biphenyls Chlorinated dibenzo-dioxins Furans
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Persistent organic pollutants (POPs)
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Persistent organic pollutants (POPs)
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Halogenated carbon-based chemicals Unchanged for long periods Organochlorine pesticides:
toxaphene, chlordane, DDT (dichloro-diphenyl-trichloroethane), mirex, aldrin, and dieldrin
Polychlorinated biphenyls, chlorinated dibenzo-dioxins and furans
Persistent organic pollutants (POPs)
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Persistent organic pollutants (POPs)
Lipophilic: liver and adipose tissue, and organisms with extensive body fat (seals)
Migrate within the ecosystem
Effect Dioxin-like
metabolic effects, cancer risk, and endocrine-mimic activity
Immune defect
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Environmental Chemicals in the Development of
Diabetes and Obesity Exposure to certain chemicals
or chemical classes has been associated with the development of diabetes or obesity in humansArsenic Persistent organic
pollutants (POPs)Bisphenol A (BPA)
Pesticides
Trialkyltins (“Organotins”)
Phthalates
Maternal Smoking
Nicotine
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Lead Child labor Pesticides Persistent organic pollutants (POPs)
Fluoride Endocrine disruptors: POPs, arsenic
Hazards specific to children
Guidotti TL, Gitterman BA. Pediatr Clin North Am. 2007 Apr;54(2):335-50
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Fluoride
• Flurosis: Dental, skeletal
• Fluride overexposure: Africa, Middle east, India, Mexico, China, Bangaladesh
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Lead Child labor Pesticides Persistent organic pollutants (POPs)
Fluoride Endocrine disruptors: POPs, arsenic
Hazards specific to children
Guidotti TL, Gitterman BA. Pediatr Clin North Am. 2007 Apr;54(2):335-50
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Endocrine disruptors
Exogenous chemicals that mimic or modify the action of endogenous
hormones and alter the normal functioning of the endocrine system
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Endocrine disruptors
Potential adverse outcomes: neurodevelopmental, neurobehavioral, reproductive, immune related, or cancer related
Route of exposure: ingestion, transplacenta
Increasing incidence of testicular cancer, hypospadias, early onset of puberty in girls
POPs and others Low level chronic
exposures???, timing of exposure
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Arsenic
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Acute poisoning: Bangladesh, India Cancer, skin disease, neurotoxicity,
malnutrition (wasting effect)
Arsenic
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Arsenic Risk factor, along with lead, mercury,
and deficiency in omega-3 fatty acid intake reduces IQ and academic performance
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Need for Chemical Testing
Over 80,000 chemicals in commerce today Majority of chemicals in commerce are untested 100 chemicals: impair brain development in
animal models 12 chemicals (alcohol, lead, mercury, etc.):
closely associated with human cognitive impairment
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An evidence-based review of known toxic effects of selected
manufactured chemicalsChemical What is it? Where is it
found and how does exposureoccur?
Evidence-based health effects
Benzene Precursor for other chemical compounds
Air, water, soil: • outdoor air: tobacco smoke, gas stations, motor vehicle exhaust, industrial emissions • vapors from certainproducts (glues, paints, furniture wax, and detergents)•plastics, resins, nylon, synthetic fibers, rubbers, lubricants, dyes, detergents, drugs, pesticides
Carcinogenic, dizziness, tachycardia, headaches, tremors, and confusion, vomiting, gastritis, sleepiness, seizures, death, irregular menses, decrease in ovarian size
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An evidence-based review of known toxic effects of selected
manufactured chemicalsChemical
What is it? Where is it found and how does exposureoccur?
Evidence-based health effects
BPA (Bisphenol A)
used to make polycarbonateplastics and epoxy resin lining of aluminum cans
•plastic #7 products and in the plastic additive inside of aluminum cans•toys, drink containers, medical equipment (intravenous tubing), dentalsealants, liquid infant formula, canned foods, and thermal paper (paper that has been heated, such as receipts)
Associated with cardiovasculardiagnoses, type 2 diabetes, and elevatedliver enzymes; injury to placental cellsexposed to BPA
Dioxins A group of chemicals that are byproducts ofchlorination (bleaching) processes atindustrial sites and waste and watertreatment plants
air, water, and soil; these chemicals can build up in the food chain; consumptionof contaminated food (meat, diary, and fish)consists of most of the populationsexposure to this group of chemicals
carcinogenic; it also may cause dermatologic effects (chloracne,discoloration, and hirsutism), elevation ofliver enzymes, glucose metabolismalterations, and subtle hormonal changes
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Chemical What is it? Where is it found and how does exposureoccur?
Evidence-based health effects
Formaldehyde
Water-soluble gas most frequently used asa precursor to other chemical compounds
•wood products, plastics, paints, human-made fibers, fertilizer, resins, preservative in household products, or cosmetics•smog, cigarettes,gas cookers, fireplaces, medical supplies,manufactured wood products, fiberglass, carpets, permanent press fabrics, paper products,and household cleaners
•Carcinogenic•Irritation of eyes,nose, throat and skin•Exacerbates asthma
Melamine •Metabolite of a pesticide (cryomazine) •Decomposition product of a food equipment sanitizer (trichloromelamine)
•food products produced in China•plastic tableware,flame retardants, paper/paperboard, andindustrial coatings
Crystalluria irritation anywhere along the urinary tract,nephrolithiasis, or acute renal failure
An evidence-based review of known toxic effects of selected
manufactured chemicals
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Chemical What is it? Where is it found and how does exposure occur?
Evidence-based health effects
PBDEs(polybrominated diphenyl ethers)
•Flame-retardant chemicals added to plastics and foam products•Chemically related to PCBs and are considered POPs
Air, water, soil, and dust:manufacturing and use of consumer products •foam pillows, carpet padding, furniture, airplane seats, textiles, baby care items, and plastic casings of computers, cell phones, TV, and remote controls
•Learning and memory•Deficits motor changes and reactivity to the environment•Decreased thyroid level•Possible carcinogen
PCBs(polychlorinated biphenyls)
manufactured of PCBs was stopped in 1977 (toxic effects)persist for decades in theenvironment and were found in UCB of a random sample of newborns as late as 2005
•Manufactured before 1977 (fluorescent lighting fixtures, electrical devices)•Contaminated food, mainly fish, meat, anddairy products•Air near hazardouswaste sites •contaminated wellwater
•Suspected carcinogen•Preterm birth•Tooth abnormalities•Rashes •Liver damage•Motor delay and decrease in short-term memory
An evidence-based review of known toxic effects of selected
manufactured chemicals
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Chemical What is it? Where is it found and how does exposureoccur?
Evidence-based health effects
PFOAs(perfluorooctanoic acids)
Manufactured chemical that repels oil, grease, or water
•surface protection products (carpet and clothing treatments)•Coating for paper and cardboard packaging andfire-fighting foams•air, soil, food, water carried over greatdistances by groundwater or ocean currents
•At high doses, fetal weight reduction,cleft palate, delayed bone ossification,stunted mammary gland development,immunotoxicity, thyroid hormone disruption, cardiac abnormalities, and/or death
Phthalates Use in soft, flexible plastics, PVC and personal care products
•Air, water, food•Exposure: ingestion, inhalation, topical •Food packaging, medical tubing, wire insulation,construction products, and toys
•Androgenization(feminizaion) with prenatal exposure•Rhinitis, eczema, asthma in early childhood exposure
An evidence-based review of known toxic effects of selected
manufactured chemicals
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Used to make polycarbonate plastics and epoxy resin lining of aluminum cans
Found in plastic #7 products and in the plastic additive inside of aluminum cans, toys, drink containers, medical equipment (e.g., intravenous tubing), dental sealants, liquid infant formula, canned foods, and thermal paper
Cardiovascular disease, type 2 DM, and elevated liver enzymes
BPA (Bisphenol A)
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Metabolite of a pesticide (cryomazine), decomposition product of a food equipment sanitizer (trichloromelamine)
2008: food products produced in China (e.g., infant formula, foods with milk-derived ingredients, eggs, pet food);
Plastic tableware,flame retardants, paper/paperboard, and industrial coatings
Crystalluria irritation anywhere along the urinary tract, nephrolithiasis, or acute renal failure
Melamine
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Phthalates Manufactured
chemicals used in soft, flexible plastics, PVC, and personal care products
Air, water, and food Pediatric exposure
largely occurs through ingestion, sucking/mouthing plastics, dust inhalation, topical exposure;
Food packaging, medical tubing, wire insulation, construction products, and toys may contain phthalates
Androgenization (feminization) with prenatal exposure
Breast milk exposure: sex hormone disruption and human binding globulin disruption in male infants;
Early childhood exposure: rhinitis, eczema, and asthma
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Air quality
Air pollution: 3 types Ambient air pollution: CO, PM Air toxics Indoor air pollution
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Health effects of the air pollution
Neurodevelopment
Asthma: NO, O3, PM2.5
Immune effects: viral infection
Reproductive Lung capacity:
NO, PM2.5 Atopy? ETS: asthma,
pneumonia, middle ear infection, SIDS
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Asthma host defenses and immune
effects reproductive outcomes The early development of lung
capacity Asthma is triggered by several
air pollutants individually and in combination, including oxides of nitrogen, ozone, and fine particulate matter
Ambient air pollution
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Indoor air pollution
• Acute lower respiratory tract infections,
• Severe infant morbidity and mortality
• Environmental tobacco smoke: increased incidence of asthma, pneumonia, and middle ear effusion
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Precursor for other chemical compounds Found in air, water, and soil
outdoor air: tobacco smoke, gas stations, motor vehicle exhaust, and industrial emissions
vapors from certain products (e.g., glues, paints, furniture wax, and detergents)
plastics, resins, nylon, synthetic fibers,rubbers, lubricants, dyes, detergents,drugs, and pesticides
Carcinogenic Drowsiness, dizziness, tachycardia,headaches, tremors, and
confusion, vomiting, gastritis, sleepiness, seizures, tachycardia, or death
Irregular menses and decrease in ovarian size
Benzene
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When giving anticipatory guidance, should
recognize that although no one can do everything,
everyone can do something.
Anticipatory guidance
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Avoid pesticides Use non-toxic products Clean up indoor air Eat healthy Be wise with plastics
Anticipatory guidance for patients and families
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Agency for Toxic Substances and Disease Registry: http://www.atsdr.cdc.gov
Centers for Disease Control & Prevention: http://www.cdc.gov/environmental/
EnviRN Knowledge Network, Nursing and Environmental Health: http://envirn.org
Pediatric Environmental Health Specialty Units: http://www.aoec.org/pehsu.htm
World Health Organization: http://www.who.int/ceh/en/
Resources
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