The Environment and Child Health: recent evidence

1. The Environment and Child Health: recent evidence David K. Becker, MD, MPH Associate Clinical Professor UCSF Department of Pediatrics UCSF Osher Center for Integrative Medicine CHE Partner Call September, 2010

2. The Environment and Children’s Health • Chemicals, pesticides, accumulation of old and new toxic components in our environment that can have direct or indirect, obvious or subtle, acute or chronic effects on child health • Nutrition – quantity, whole foods, least-processed, organic? • Nature – the most recent data are investigating the health benefits of ‘green’ space and ‘free play.’ • Today: • Brief review of data on pesticide residues and health effects • What do we know about green space and child mental health

3. Data on OP exposure and neurodevelopment • Although research is limited, a few recent epidemiologic studies have reported on associations between OP exposure and neurodevelopment (Engel et al. 2007; Eskenazi et al.2007; Grandjean et al. 2006; Rauh et al. 2006; Young et al. 2005). • Found that biomarkers of prenatal OP exposure are associated with increased number of abnormal neonatal reflexes as measured by the Brazelton Scales of Neonatal Development (Engel et al. 2007;Young et al. 2005) • and poorer performance on mental development on the BayleyScales of Infant development (Eskenazi et al. 2007; Rauh et al. 2006). • Rauh et al. (2006) also reported in a cohort of 3-year olds living in New York City (NYC) that concentrations of chlorpyrifos, an OP pesticide, in maternal serum was associated with the mothers’ report of symptoms consistent with pervasive developmental disorder (PDD), as well as of attention deficit hyperactivity disorder (ADHD) or attention problems.

4. Organophosphate Pesticide Exposure and Attentionin Young Mexican-American Children Marks AR, Harley K, Bradman A, Kogut K, Barr DB, et al. 2010 Organophosphate Pesticide Exposure and Attention in Young Mexican-American Children. Environ Health Perspect doi:10.1289/ehp.1002056 • Investigated whether OP exposure, as measured by maternal urinary dialkyl phosphate (DAP) metabolites during pregnancy, was associated with attention-related outcomes among Mexican-American children living in the agricultural Salinas Valley and followed to ages 3½ (n=331) and 5 (n=323) years (of 540 recruited in 1999/2000) • In utero DAPs wereassociated adversely with attention in young children as assessed by maternal report, psychometrician observation, and direct assessment. These associations were more robust at 5 than 3½ years and stronger in boys.

5. ADHD and urinary metabolites of organophosphates Pediatrics. 125(6); 2010 • National sample (1139; NHANES); 8-15 yrs; structure interview assessment by phone • Intended to sample ‘average levels of exposure’ • Urinary DAP (dialkyl phosphate) measurement • A 10-fold increase in DMAP conc: OR 1.55 (1.14-2.10) • Most common DMAO metabolite (dimethylthiophosphate): higher than median levels assoc with doubling the odds of ADHD.

6. Organic Diets Significantly Lower Children’s Dietary Exposure to Organophosphorus Pesticides Environ Health Perspect 114:260–263 (2006). • substituted most of children’s conventional diets with organic food items for 5 consecutive days • Collected daily urine samples throughout the 15-day study period • median urinary concentrations of metabolites for malathion and chlorpyrifosdecreased to the nondetect levels immediately after the introduction of organic diets and remained nondetectable until the conventional diets were reintroduced.

7. Nature and Mental Health We’re all familiar with benefits of physical activity Obesity Cardiovascular health Chronic pain Psychological health Many others Data on ‘green’ space/exercise and ‘free play’ are more sparse, particularly in relation to mental health.

8. Positive impact of free outdoor play on children’s emotional and physical health • AAP report: “The Importance of Play in Promoting Healthy Child Development and Maintaining Strong Parent-Child Bonds,” written in defense of play and in response to forces threatening free play and unscheduled time. • “Pediatricians can promote free play as a healthy, essential part of childhood. They should recommend that all children are afforded ample, unscheduled, independent, non-screen time to be creative, to reflect, and to decompress.” • Absent was a discussion of the importance of ‘green’ space

9. Changes in type of play and inclusiveness with ‘green space’ JE Dyment AC Bell. Grounds for movement: green school grounds as sites for promoting physical Activity. Health Education Research. 23(6); 2008: 952–962 • Canadian study of 59 schools across the country • “Complementing competitive games on asphalt and turf, green school grounds invite children to get moving in ways that nurture all aspects of their health and development, like encouraging moderate and light levels of physical activity by increasing the range of enjoyable, non-competitive, open-ended forms of play.”

10. Changes in type of play and inclusiveness with ‘green space’

11. Review of health benefits of exposure to natural environments Systematic review of benefits of ‘natural’ environment activities vs. built environment (all ages, 25 studies, meta-analysis showed evidence of positive effects) Included 3 studies on attention/concentration in children: Faber Taylor A, Kuo FE, Sullivan WC: Coping with ADD: the surprising connection to green play setting. Environ Behav 2001, 33:54-77. Kuo FE, Faber Taylor A: A potential natural treatment for Attention- Deficit/Hyperactivity Disorder: evidence from a national study. Am J Public Health 2004, 94:1580-1586. Commonly cited; parent-reported benefits of green space activities in national sample Faber Taylor A, Kuo FE: Children with attention deficits concentrate better after walk in the park. J Atten Disord 2009, 12:402-409. Bowler DE et al. BMC Pub Health. 2010, 10:456

12. Children with attention deficits concentrate better after walk in the park J AttenDisord 2008 Kuo FE. A potential natural treatment for attention-deficit/hyperactivity disorder: evidence from a national study. Am J Public Health 94:1580-6 • Small sample of 17 children (15 boys; 7-12 yrs) • Randomized to 3 controlled, guided walks of 20 min • urban park • downtown area • residential area • Children with attention deficits concentrated better after walking in a park than after either of two other settings. • The effect of a dose of green was roughly as large as the deficit due to ADHD and roughly as large as the peak effect of extended-release methylphenidate. • Children’s experience of the three settings showed the same pattern as their attention performance afterward. • The park was experienced significantly more positively than the other two settings.

13. What we can do with this knowledge… National Environmental Education Foundation (NEEF) Tools for healthcare providers to become leaders in their community Children and Nature Initiative educates pediatric health care providers about prescribing outdoor activities to children. connects health care providers with local nature sites so that they can refer families to safe and easily accessible outdoor areas. Benefits: public health-provider collaboration leverages the strengths of both

14. What we can do with this knowledge… • Children and Nature Network • Co-founded by Richard Louv: Last Child in the Woods: saving our children from nature-deficit disorder. • Also has resources and a network of • Map of outdoor opportunities/programs nation-wide to connect with

15. What we can do with this knowledge… • Locally… Golden Gate National Parks Conservancy • National Institute of the Golden Gate has developed its own Parks Prescription program