Disclosures: None Painted by Berlinghiero 1230 CE Madonna and - - PDF document

Pediatric and Environmentally Exposed: Doubly Vulnerable

Staff Physician, Western States PEHSU Volunteer Assistant Clinical Professor, UCSF PhD Student in Epidemiology, UC Berkeley

Stephanie Holm, MD MPH FAAP

Disclosures: None

Madonna and Child

Painted by Berlinghiero 1230 CE

Children are NOT small adults!

HOWEVER

Children are human!

Why are Children More Vulnerable?

1. Behaviors and Preferences that Increase Exposure 2. Differences in Physiology that increase Dose 3. Unique Windows of Development

Behaviors and Preferences that Increase Exposure

• Mouthing objects‐increased ingestion
• Hands contacting the floor‐increased ingestion
• Inability to assess risk
• Often have higher exercise time relative to adults

PBDE Exposure

• Brominated Hydrocarbon flame retardants
• Common in foam products until 2013
• Broken down foam settles in dust; high levels

remain even in areas where it was phased out

• Associated with neurobehavioral , liver and thyroid

effects in animal studies

• In children, associated with deficits

in attention and executive functioning, possibly with leukemia

Behaviors and Preferences that Increase Exposure‐ Diet

• Up to 4‐6 months of age‐ formula/breastmilk only
• Mercury in breastmilk
• Clean water for formula
• Minimizing clear plastics
• Small children often eat limited fruits and veggies
• often ones with high pesticide exposures

Arsenic

• Rice cereal was often recommended as a first food

historically

• Apple products (apple sauce, apple juice also high

in arsenic)

• Also of particular concern for older children with

restricted diets (such as gluten‐free)

Behaviors and Preferences that Increase Exposure‐Surroundings

• More time at home
• Airborne‐ radon, PM, second‐hand tobacco, aerosols

from cleaning products

• Dust‐ lead, PBDEs
• Young children‐ care settings (either other homes
• r Early Care and Education settings)
• VOCs in arts/craft supplies
• Disinfectants
• Older Children‐ School, activities
• Teens‐ School, activities, workplaces, hobbies

Early Care and Education

• One of the few locations where

disinfectant use is mandated with children present

• Bleach and quaternary ammonia

products are asthmagens

Differences in Physiology that Increase Dose

• Rapid growth with higher metabolic rate
• Eat more food
• Drink more water
• Breathe more air
• Larger Body surface to mass ratio
• Longer remaining life‐expectancy
• Breathing zone closer to the floor
• Some enzymes for processing/clearing

toxicants are still developing

Air Pollutants

• Per kg of body weight, a one‐year old has a minute

ventilation that is TWICE that of an adult.

• Both short and long‐term ozone exposure is related

to decrements in FEV1 in children, but less reliably in adults

• More frequent respiratory infections

(otitis, pneumonia, etc)

• Risk in‐utero as well

https://envhealthcenters.usc.edu/infographics/infographic‐cleaner‐air‐healthier‐lungs

Windows of Susceptibility

• Small molecules and fat soluble molecules can

cross the placenta

• Because of rapid growth, many dividing cells
• Lead exposure in infancy/toddlerhood particularly

problematic

• Adolescents have rapid gonadal

development

Adverse Childhood Events (ACEs)

• Associated with a spectrum of health effects across

the life course (including cancer, heart disease, diabetes, respiratory disease)

• Children exposed to violence and air pollution are

at increased risk of developing asthma

• Early life stress thought to be able to

reprogram the HPA axis

• Some studies have found strongest

effects for ACEs in early childhood

Taking a Pediatric Environmental Health History

• Home
• School
• Workplace (teens)
• Community
• Tobacco
• Water Source
• Diet
• Sun
• Take‐Home Exposures

Pediatric Environmental Health Toolkit

peht.ucsf.edu

Optimized for Mobile!

For further education on environmental health through the lifecourse (with CME available!)

Western States PEHSU wspehsu.ucsf.edu

Don’t forget about the benefits of childhood!

When you grow up, people stop asking what your favorite dinosaur is. It’s like they don’t even care.

References

• Agency for Toxic Substances and Disease Registry: Principles of Pediatric

Environmental Health. What are Factors Affecting Children’s Susceptibility to Exposures? https://www.atsdr.cdc.gov/csem/csem.asp?csem=27&po=6 Atlanta, GA 2013

• Pediatric Environmental Health, 3rd Edition. Edited by Ruth A. Etzel and

Sophie J. Balk. Itasca, IL, American Academy of Pediatrics, 2011

• Pediatric Environmental Health Specialty Units. https://www.pehsu.net/

Washington, DC 2019

• Western States Pediatric Environmental Health : Pediatric

Environmental Health Toolkit. https://peht.ucsf.edu/index.php San Francisco, CA 2016

• American Association of Poison Control Centers. https://aapcc.org

Alexandria, VA 2017

• Miller MD and Marty MA: Childhood ‐ A Time Period Uniquely

Vulnerable to Environmental Exposures in The Praeger Handbook of Environmental Health, edited by Robert H. Friis, Santa Barbara, CA, ABC‐CLIO LLC, 2012, p 203

Children should be considered differently than adults because:

A. They have a higher metabolic rate B. They have a higher surface area to mass ratio C. They have particular windows of susceptibility D. All of the above

Adverse Childhood Experiences:

A. Do not affect adult health outcomes B. Do not have interactive effects with environmental exposures C. Are stressful or traumatic events occurring in childhood

Minute Ventilation by weight in a 1 year old is roughly __ times that in adults (Adults are roughly 0.1L/kg)

A. 0.5 B. 1 C. 2 D. 4

Diplodocus carnegii

Statue in Pittsburgh, PA

Photograph by Wally Gobetz, used under CC license: https://creativecommons.org/licenses/by‐nc‐nd/2.0/

@dippy_the_dino: https://twitter.com/dippy_the_dino?lang=en