Out of Harm’s Way: Preventing Toxic Threats to Child Development

Oregon Physicians for Social ResponsibilityOctober 2007

www.oregonpsr.org

•Scope of the problem of neurodevelopmental & learning disabilities.

Human vulnerability to toxic chemicals, focusing on children.

Current chemical environment, focusing on lead, mercury & pesticides in Oregon.

What you can do to help your patients minimize and, ideally, prevent exposures.

Today’s Presentation

Prevalence of Learning and Behavioral Disabilities

Total: 17%, 12 million children

• Learning disabilities: 5-10%

• ADHD: 1-20%

• Autism: .3-.66%

Reported Trends: Real? Better reporting? Changing criteria?

Learning disabilities

191% Special Ed: 1977-1994

ADHD 1- 20% Reported prevalence

>800% Ritalin since 1971

Economic Implications

$81.5 – $167 billion/yr: Neurodevelop-mental deficits & related disorders.

$9.2 billion/yr: Attributable to environmental pollutants.

$80-100,000/yr: Residential treatment for a child with autism.

$800 million/yr: OR special ed costs.

NUTRITION

Traits/ Abilities

DevelopmentalSyndromes

ADHD Autism

Learning disability

SOCIAL ENVIRONMENT

GENETICS

Framework for Understanding

NUTRITION

Asperger’s syndrome

TOXICANTS

???

Embryonic Development & Vulnerability

Children are More Vulnerable to All Toxins

Eat, breathe & drink more per lb; Mouth breathers; Immature brain, blood/brain barrier; GI & skin 2x surface area vs adult; Outside more & closer to ground; Hand/mouth behaviors; Lower enzyme levels.

The Significance of Small Effects: EFFECTS OF A SMALL SHIFT IN IQ DISTRIBUTION IN A

POPULATION OF 260 MILLION

160140120100806040

70 130I.Q.

mean 100

6.0 million "gifted"

6.0 million "mentally retarded"

5 Point Decrease in Mean IQ just one IQ point drop ~ 2.4% reduction in lifetime earnings

160140120100806040

mean 95

70 130

2.4 million "gifted"

9.4 million "mentally retarded"

57% INCREASE IN

"MentallyRetarded”Population

I.Q.

Our Chemical Environment: The State of Knowledge

>82,000 chemicals. est. 700 new chemicals/year. >4 billion lbs per year, inc. 72 million lbs carcinogens. Basic Screening Information Data Set (SIDS) ~$205,000/chemical.

Problem:Problem: Data available for just a few chemicals. No data available for majority!

Developmental Testing of Chemicals Produced @ > 1 million lbs/year

33.1%

0.4%

78.2%

No DataOn DevelopmentalToxicity

Only 12 Tested for NeurodevelopmentalToxicityAccording to EPAGuidelines

Some DataOn DevelopmentalToxicity

PROVEN HARM

PARTIALLY PROVEN

NOT YET RECOGNIZED

FOREVER UNRECOGNIZED

THE TOXIC ICEBERG

lead

0.1

1

10

100EX

PO

SU

RE –

blo

od

lead

, u

g/d

l

DECLINING THRESHOLD OF HARM - LEAD

ReportedHarm (CDC)

?New Level?

YEAR REPORTED

1960 1970 1980 1990 2000

Lead (Pb): a Persistent Problem

Nationally: 2.2% have BLL predictive of lower IQ. New data: BLL<10 may reduce IQ more than higher

levels, affecting up to 16% children. Oregon: 2% homes high risk & 1% tested kids<6yo

have elevated BLL. Multnomah County: 4% homes high risk. Lead phase out: paint 70s; gas 80s; plumbing 1985. Lack of OR regulation: 19/48 industries air & 5/18

water have permits – we know nothing about the rest. Increase in immigrants

ADHD LD OTHER

hyperactivity reading, math fine motor impulsivity spelling visual motor distractibility pattern recognition aggressive dif. w. instructs word recognition antisocial conduct problems off-task executive function attention/vigilance social skills

Effects of Lead on Cognitive and Behavioral Traits

Other Health Effects of Lead Exposure

Chronic renal disease, nephritis Dementia atherosclerosis Peripheral neuropathy Behavioral changes Reduced sperm count and libido Miscarriages Hypertension

Sources of Lead

Old paint & water pipesHome renovation (in dust)Gasoline (soil contamination and bio-accumulation in

root>stem>leafy vegetables)Industrial/workplace emissionsHobbies-lead solder Bone release during pregnancy if calcium deficientBreast MilkCostume jewelry & under-fired terra cottaMexican folk remediesVinyl and non-glossy mini-blinds

Advise Patients

Clean up paint chips, keep paint in good condition; Regularly clean areas where children play; Wash toys, stuffed animals, bottles & pacifiers often; Clean/remove shoes outside; Test homes built before 1978, esp. if being remodeled Test drinking water & replace Pb solder-if unable, use

COLD water. Testing for all immigrants, Medicaid patients & low SES Call the Multnomah Co Lead Line 503-988-4000: free tap water testing, BLL clinics, safe home remodeling,

risk assessment help

Mercury (Hg): a Persistent Problem

Poisonings: Minamata 1950s & Iraq 1971. Nationally: EPA est.160 tons released annually. In Oregon: 4,500 lbs released from human

sources annually. Lack of OR regulation: 10 facilities report Hg

release-none required to monitor emissions by state.

The Mercury Cycle

Sources of Mercury

Industrial emissionsMunicipal & medical

incineratorsAbandoned Hg & gold

minesNatural off-gassing Dental amalgamsBioaccumulation in

foodsOld thermometers, BP

cuffs & auto switches

Health Effects of Mercury

Cerebral palsy MR/DD balance problems hearing loss/deafness visual impairment/blindness peripheral neuropathy seizures abnl reflexes & muscle tone Psychiatric disturbances

Mercury Exposures

5-8% of women of reproductive age exceed recommended Reference Dose (RfD) of 1ug/kg/day.

50% of women who eat fish exceed RfD on any given day.

Higher risk: Children of women with higher Hg intake (est. 300k/yr); Subsistence fishers, immigrants, Native Americans.

Fish Advisories: in 2004, 44 states had >2k warnings; OR lists 16 water bodies.

Mercury:Declining Threshold of Harm

20001990198019700.01

0.1

1

10

100

YEAR

Level associated with

harmful effectRegulatory standard

(maximum safe exposure or high end exposure from allowed fish

contamination)

FDA WHO

EPA

ATSDR

DA

ILY

IN

TA

KE

(mic

rogr

ams/

kg/

day

Hg)

Benefits of Maternal Fish Consumption Lessened by Hg Exposure

Fish is a good food source: protein, iron, vitamin E, selenium, and

long chain n-3 polyunsaturated fatty acids Higher fish consumption associated with

improved infant cognition However...Higher Hg (even very low dose)

associated with reduced cognition

Eat more fish with less mercuryOken E et al., EHP 2005

Advise Patients

Have car checked for Hg switches at participating auto shop (free replacement w/nonHg switch).

Use digital thermometers & thermostats.

Recycle old Hg thermometers, thermostats & fluorescent light tubes: 1-800-RECYCLE

Provide pregnant women copies of Healthy Fish, Healthy Families (PSR) and An Expectant Mother’s Guide to Eating Fish in Oregon (DHS)

Recommend children <6yr and women of child bearing age avoid fish high in mercury.

Guide to Healthy Fish

AVOID: Mackerel-King, Shark, Swordfish, Tilefish; In OR, also Bass (large & smallmouth), Brown Trout.

<2 servings/month (Hg &/or PCBs): Salmon, Sardines, Herring, Bluefish.

<1 serving/wk: Lobster, Tuna, Mackerel-Spanish, Marlin, Orange Roughy, Grouper; In OR, also Walleye, Carp, Catfish, Sturgeon.

CHECK LOCAL AND STATE FISH ADVISORIES at

www.healthoregon.org/fishadv

How Much Fish is Safe?

•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!

IATP Fish Calculator

www.iatp.org

Pesticides: a Persistent Problem

Definition: Physical, chemical or biological agent intended to kill an undesirable plant or animal pest.

Major classes: insecticides, fungicides, herbicides. Market: in 1997, USA $11.9 billion & World $37 billion. History: new to humans & environment since 1940s; over

800 licensed as “active” ingredients by EPA. Inherent toxicity: 140 pesticides considered neurotoxic,

37 used on food &/or feed.

Organophosphate Pesticides

Occurrence and distribution of 11 types in surface & ground water of the United States, 1992-97

http://ga.water.usgs.gov/publications/abstracts/ofr00-187.html

Pesticides and Children

Associations noted with:– Neurodegenerative disorders

Parkinson's Disease– Birth defects– Neurodevelopmental disorders– Leukemia – Non-Hodgkin’s lymphoma– Soft tissue sarcoma– Brain tumors

Same tumors repeatedly found in adult studies.

Zahm SH, Ward MH., EHP 1998

Background Pesticide Exposures Widespread

Reported use: 98% of families, 80% during pregnancy. In Humans: detectable chlorpyrifos metabolites in 92%

children’s, 82% adults’ urine. Food: detectable residues of at least 1 pesticide on 72%

fruits & vegetables (not sustainably grown). In Homes: 3 to 9 pesticide residues found; 70% of infant

levels from dust. In Air: indoor levels 10 to 100X higher than outdoor air. In Water: >90% stream samples, 50% of wells.

Pesticides: the Health EffectsYaqui Indian Pesticide - Anthropomorphic Study

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

Advise Patients

Regularly clean areas where children play; Use IPM and nontoxic products in yard; Clean/remove shoes outside; Buy organic food or, when unable, clean

non-organic produce; Store food in secure nontoxic containers. Select lawn care & pest control companies

which use IPM and nontoxic products.

Advice for Buying OrganicPesticide Report Card

Environmental Working Group www.ewg.org

Emerging Themes

The more we learn about chemicals, the lower the toxic thresholds tend to fall.

Animal testing for NDT underpredicts human vulnerability by a factor of 100 to 10,000.

Subtle effects carry profound impacts when expressed over a population (IQ).

Adverse effects of toxins are often synergistic-advisories based on analysis of a single chemical are unlikely to protect public health.

Conclusions

Guiding Principles

Disabilities are widespread. Toxic exposures are preventable contributors.

Apparent toxicity at high doses is a red flag for possible harm from low dose exposures.

Since “proof” of harm materializes slowly, generations are being put at risk before adequate regulatory response occurs.

To protect public health, we need a flexible regulatory system capable of preventing (as well as responding to) exposures.

Conclusions

Be aware of environmental toxins & possible effects. Provide education on prevention and minimizing

exposures. Additional resources, incl. research articles and patient fact sheets, available at www.oregonpsr.org

Incorporate the Pediatric Environmental Health Toolkit into your practice:

http://psr.igc.org/ped-toolkit-materials.htm Advocate for a healthier environment:

www.envirohealthaction.org

Conclusions

What Can You Do??

“When an activity raises threats of harm

to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically.”

Wingspread Conference, 1998.

Precautionary Principle

Breastfeeding is Best for Baby

Taking An 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, fishingOccupation – known exposures, fumes, dusts,

vapors, Material Safety Data Sheets

Oral behaviors – pica/mouthing

Strategies to Reduce Lead Pollution in Oregon

Policy Solutions: Remediate Pb paint in homes & apartments. Act on Blood lead level >2. Ensure all Medicaid children tested for BLL. Test schools & child care facilities for Pb paint &

drinking water. Ensure recycling of Pb products (batteries &

computer monitors). Require DEQ to set permit limits for industrial

release of Pb.

Strategies to Reduce Mercury Pollution in Oregon

Policy Solutions: Mercury Solutions Act 2001 Eliminate Hg from industrial equipment Recycle Hg products (fluorescent light tubes) Clean up mines and Superfund sites Reduce Hg from dental offices, labs & health care

facilities (OCEH-HCWH/H2E) Include Hg in applicable DEQ air & water permits Mandate point sources adopt Clean Air Act

technologies Implement Oregon’s Executive Order

Strategies to Reduces Exposure to Home & Garden Pesticides in Oregon

Policy Solutions: Oregon’s pesticide use reporting system (1999)

finally funded. Educate homeowners re: non/low toxic options. Encourage schools, childcare facilities & local

governments to use Integrated Pest Management (IPM), i.e. Pesticide Free Parks.

Encourage pet owners to use flea combs and vacuuming to control fleas.

Ask retailers to educate customers about safer alternatives and IPM.

Acknowledgments

Greater Boston Physicians for Social Responsibility Washington Physicians for Social Responsibility Ted Schettler, MD, MPH Steven G. Gilbert, PhD, DABT Richard Grady, MD Catherine Thomasson, MD Michelle Gottlieb Maria Valenti Jill Stein David Wallinga, MD