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

1. Out of Harm’s Way: Preventing Toxic Threats to Child Development Oregon Physicians for Social Responsibility October 2007 www.oregonpsr.org

2. Today’s Presentation • 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.

3. Prevalence of Learning and Behavioral Disabilities • Total: 17%, 12 million children • Learning disabilities: 5-10% • ADHD: 1-20% • Autism: .3-.66%

4. Reported Trends: Real? Better reporting? Changing criteria? • Learning disabilities • 191% Special Ed: 1977-1994 • ADHD • 1- 20%Reported prevalence • >800%Ritalin since 1971

5. 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.

6. NUTRITION GENETICS SOCIAL ENVIRONMENT Framework for Understanding TOXICANTS Traits/ Abilities NUTRITION Asperger’s syndrome Learning ??? disability ADHD Autism Developmental Syndromes

8. 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.

9. 80 40 60 100 120 140 160 70 130 The Significance of Small Effects:EFFECTS OF A SMALL SHIFT IN IQ DISTRIBUTION IN A POPULATION OF 260 MILLION mean 100 6.0 million 6.0 million "mentally retarded" "gifted" I.Q.

10. 40 80 100 120 140 160 60 70 130 5 Point Decrease in Mean IQjust one IQ point drop ~ 2.4% reduction in lifetime earnings mean 95 57% INCREASE IN "Mentally Retarded” Population 2.4 million 9.4 million "gifted" "mentally retarded" I.Q.

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

12. Developmental Testing of Chemicals Produced @ > 1 million lbs/year Some Data On Developmental Toxicity Only 12 Tested for Neurodevelopmental Toxicity According to EPA Guidelines No Data On Developmental Toxicity

14. 1960 1970 1980 1990 2000 DECLINING THRESHOLD OF HARM - LEAD lead 100 Reported Harm (CDC) 10 EXPOSURE – blood lead, ug/dl ?New Level? 1 0.1 YEAR REPORTED

15. 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

16. Effects of Lead on Cognitive and Behavioral Traits • 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

17. Other Health Effects of Lead Exposure • Chronic renal disease, nephritis • Dementia • atherosclerosis • Peripheral neuropathy • Behavioral changes • Reduced sperm count and libido • Miscarriages • Hypertension

18. Sources of Lead Old paint & water pipes Home renovation (in dust) Gasoline (soil contamination and bio-accumulation in root>stem>leafy vegetables) Industrial/workplace emissions Hobbies-lead solder Bone release during pregnancy if calcium deficient Breast Milk Costume jewelry & under-fired terra cotta Mexican folk remedies Vinyl and non-glossy mini-blinds

19. 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

20. 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.

22. The Mercury Cycle

23. Sources of Mercury Industrial emissions Municipal & medical incinerators Abandoned Hg & gold mines Natural off-gassing Dental amalgams Bioaccumulation in foods Old thermometers, BP cuffs & auto switches

24. 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

25. 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.

26. 100 10 1 0.1 0.01 1970 1980 1990 2000 Mercury:Declining Threshold of Harm Level associated with harmful effect Regulatory standard (maximum safe exposure or high contamination) end exposure from allowed fish (micrograms/kg/day Hg) DAILY INTAKE FDA WHO ATSDR EPA YEAR

27. 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 mercury Oken E et al., EHP 2005

28. 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.

29. 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

30. How Much Fish is Safe? IATP Fish Calculator Enter your body weight in pounds: • 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. Select the species of fish you eat: Get your Results! www.iatp.org

31. 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.

32. 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

33. 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

34. 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.

36. 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

37. 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.

38. Advice for Buying OrganicPesticide Report Card Environmental Working Group www.ewg.org

39. Conclusions 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.

40. 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.

41. Conclusions What Can You Do?? • 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

42. Precautionary Principle “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.

43. Breastfeeding is Best for Baby

44. 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, fishing • Occupation – known exposures, fumes, dusts, vapors, Material Safety Data Sheets • Oral behaviors – pica/mouthing

45. 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.

46. 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

47. 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.

48. 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