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Preface by Dr. David Satcher
ATSDR Information Center, Child Health Collection
1600 Clifton Road NE (E-57)
Atlanta, Georgia 30333
(404) 639-6357
CONTRIBUTORS Board of Scientific Counselors, Child Health Workgroup, ATSDR Agency Roundtable on Child Health (ARCH), Non-government Partner Organizations, Reviewers, and Acknowledgments
CHILDREN AND HAZARDOUS WASTE SITES The Unique Susceptibility of Children The Imperative of Programs for Children's Environmental Health
ATSDR'S MISSION AND PROGRAMS Hazardous Waste Sites ATSDR's Public Health Programs The Impact of ATSDR's Programs on Children The Child Health Workgroup
CHILD HEALTH WORKGROUP RECOMMENDATIONS
Agencywide Recommendations
Divisional Reports and Recommendations
Division of Toxicology
Division of Health Assessment and Consultation
Division of Health Studies
Division of Health Education and Promotion
Roles of Other Agencies and Organizations
RESOURCES Bibliography Sources of Information Glossary
Cynthia F. Bearer, M.D., Ph.D.
Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland, Ohio
David Bellinger, Ph.D., M.Sc.
Harvard Medical School, Neuroepidemiology Unit, Children's Hospital, Boston, Massachusetts
Gershon H. Bergeisen, M.D., M.P.H.
U.S. Environmental Protection Agency, Office of Emergency and Remedial Response, Washington, D.C.
Joy E. Carlson, M.P.H.
Children's Environmental Health Network, Emeryville, California
Joan M. Cranmer, Ph.D.
University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
Carole A. Kimmel, Ph.D.
U.S. Food and Drug Administration, and the U.S. Environmental Protection Agency, National
Center for Environmental Assessment, Washington, D.C.
Philip J. Landrigan, M.D., M.Sc.
Mount Sinai School of Medicine, New York, New York
Susanne T. White-Sims, M.D., M.P.H.
Louisiana State University Medical Center, New Orleans, Louisiana
ATSDR STAFF
Barry L. Johnson, Ph.D., Assistant Surgeon General, Assistant Administrator
Robert W. Amler, M.D., M.S., Chief Medical Officer
Patricia H. Price, D.O., Medical Officer
Priscilla L. Young, M.D., M.P.H., Medical Officer
American Academy of Pediatrics 141 Northwest Point Boulevard Elk Grove Village, Illinois 60009-0927 American Association of Occupational Health Nurses 50 Lenox Pointe Atlanta, Georgia 30324-3176 American Association of Poison Control Centers 3201 New Mexico Avenue, NW, Suite 310 Washington, D.C. 20016 American College of Occupational and Environmental Medicine 55 West Seegers Road Arlington Heights, Illinois 60005 American Medical Association 515 North State Street Chicago, Illinois 60610 American Public Health Association 1015 Fifteenth Street, NW Washington, D.C. 20005 Association of Occupational and Environmental Clinics 1010 Vermont Avenue, NW (#513) Washington, D.C. 20005 Association of State and Territorial Health Officials 415 Second Street, N.E., Suite 200 Washington, D.C. 20002 Children's Environmental Health Network 5900 Hollis Street, Suite E Emeryville, California 94608 Learning Disabilities Association of America 4156 Library Road Pittsburgh, Pennsylvania 15234 March of Dimes Birth Defects Foundation 1275 Mamaroneck Avenue White Plains, New York 10605 National Association of Children's Hospitals and Related Institutions 410 Wythe Street Alexandria, Virginia 22314 National Association of County and City Health Officials 440 First Street, NW Washington, D.C. 20001 National Environmental Health Association 720 South Colorado Blvd., South Tower, Suite 970 Denver, Colorado 80222 National PTA 330 North Wabash Avenue, Suite 2100 Chicago, Illinois 60611-3690 Physicians for Social Responsibility 1101 Fourteenth Street, NW, Suite 700 Washington, D.C. 20005 Sierra Club 85 Second St., Second Floor San Francisco, California 94105-3441
The following reviewers have read and contributed comments during the development of this document. The workgroup is grateful for their thoughtful input. Sheila Abraham, Ph.D. State of Ohio Environmental Protection Agency Duane Alexander, M.D. National Institutes of Health, National Institute of Child Health and Human Development Sophie J. Balk, M.D. Albert Einstein College of Medicine of Yeshiva University CAPT Lawrence Betts, M.D., Ph.D. Navy Environmental Health Center, Norfolk Virginia Germaine M. Buck, Ph.D. University at Buffalo, School of Medicine and Biomedical Sciences David J. Carver U.S. Environmental Protection Agency, Office of Solid Waste and Emergency Response Dawn N. Castillo, M.P.H. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health Lorna McLeod English Centers for Disease Control and Prevention, Office of Program Planning and Evaluation Steven A. Esrey, Ph.D. UNICEF Ruth A. Etzel, M.D., Ph.D. American Academy of Pediatrics Barbara Hostage U.S. Environmental Protection Agency, Office of Solid Waste and Emergency Response Eric Juzenas, M.P.H., J.D. American Public Health Association Wanda K. Jones, Dr.P.H. Centers for Disease Control and Prevention, Office of Women's Health Howard M. Kipen, M.D., M.P.H. Environmental and Occupational Health Sciences Institute Katherine H. Kirkland, M.P.H. Association of Occupational and Environmental Clinics Heidi M. Klein, M.S. National Association of County and City Health Officials Yvonne H. Lewis Centers for Disease Control and Prevention, Office of the Director James M. Lyznicki, M.S., M.P.H. American Medical Association Thomas J. Mason, Ph.D. University of South Florida, College of Public Health Audrey R. McMahon Learning Disabilities Association of America John R. Moore, Ph.D. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion Peter M. Nakamura, M.D., M.P.H. State of Alaska, Department of Health and Social Services Timothy F. O'Leary Association of State and Territorial Health Officials Robert G. Robinson, M.S.W., Dr.P.H. Centers for Disease Control and Prevention, Office of the Director Jeffrey N. Roseman, M.D., Ph.D. University of Alabama at Birmingham, School of Public Health Lisa Rosenblum, M.D., M.P.H. Centers for Disease Control and Prevention, National Center for Environmental Health Mark D. Saperstein, D.Env. ARCO B.A. Schwetz, D.V.M., Ph.D. Food and Drug Administration, National Center for Toxicological Research Katherine M. Shea, M.D. Chapel Hill, North Carolina Babasaheb Sonawane, Ph.D. U.S. Environmental Protection Agency, Office of Research and Development Laura Thacker National Environmental Health Association Rueben C. Warren, D.D.S., Dr.P.H. Centers for Disease Control and Prevention, Office of the Director Virginia M. Weaver, M.D., M.P.H. Johns Hopkins University, School of Hygiene and Public Health Irene Ruth Wilkenfeld Safe Schools Geraldine C. Williamson, M.N., R.N., C.A.E. American Association of Occupational Health Nurses
The Child Health Workgroup thanks the following individuals for participating in their discussions: Lynn R. Goldman, M.D., M.P.H., U.S. Environmental Protection Agency, Office of Prevention, Pesticides, and Toxic Substances; Dawn N. Castillo, M.P.H., National Institute for Occupational Safety and Health, Lisa Rosenblum, M.D., M.P.H., National Center for Environmental Health, Lorna McCleod English, Office of Program Planning Evaluation, Centers for Disease Control and Prevention; Members of the ATSDR Agency Roundtable on Child Health (ARCH), John S. Andrews, M.D., M.P.H., Mark M. Bashor, Ph.D., JeAnne R. Burg, Ph.D., Christopher T. DeRosa, Ph.D., Maureen Y. Lichtveld, M.D., M.P.H., Jeffrey A. Lybarger, M.D., M.S., Allan S. Susten, Ph.D., Charles Xintaras, Barry L. Johnson, Ph.D., Assistant Surgeon General, Assistant Administrator, Agency for Toxic Substances and Disease Registry. The workgroup also appreciates the administrative and technical assistance of Diane Allgood, Connie Cutright, Cathy Johnson, Georgi Jones, Jeanne LaRocco, Dawn O'Connor, Sandra Malcom, Peter McCumiskey, and Steven VonAllmen. Theresa Ramsey edited the report and Patrick Brady designed the child health logo.
Are any exposure pathways unique to children?
Do children differ from adults in their weight-adjusted intake of the toxicant?
Do pharmacokinetic or pharmacodynamic parameters differ between adults and
children?
Are there adequate animal models for childhood exposure after birth?
Are there transgenerational effects?
Are there ethical and cultural consequences unique to children?
The workgroup members decided that, although key information gaps could be identified, the most important activity was to offer a critique of current processes and suggestions for change that would improve the quality of the data, the pediatric impact of prevention, and the future benefit of the ATSDR's activities for the children being served. This critique has become the main focus of their recommendations for the agency and its four divisions.
RECOMMENDATIONS
Vision
1. ATSDR should enlarge its institutional scope and vision to systematically include,
in explicit and structured ways, issues of child health in all activities of the agency.
2. ATSDR should review its vision, mission, and goal statements in light of the Child
Health Initiative to see if children should be explicitly included.
3. ATSDR should explore the scope of its mandate to include building expertise within
the nation's biomedical community to address the issues of children's responses to
environmental toxicants.
Program
4. ATSDR should require that all its activities be reviewed to ensure the consideration
of child health issues. (See questions.)
5. All of ATSDR's public outreach activities need to be fully studied to assess the
ethical ramifications for children.
Collaboration
6. ATSDR should ensure the widest collaboration among agencies on children's environmental health issues by developing review and discussion at the highest levels of government.
Education
7. ATSDR should build expertise in children's environmental health issues through education of biomedical scientists, physicians and other practitioners, the public, teachers, and children.
ATSDR has long advocated a comprehensive approach to promoting the environmental health of children. ATSDR has confirmed from more than 10 years of public health assessments, toxicologic investigations, epidemiologic studies, and reviews by expert workgroups that children have unique characteristics that often place them at greater risk of adverse health effects when exposed to toxic substances emitted from hazardous waste sites or chemical releases. Children who live near hazardous waste sites may have greater exposures, greater potential for health problems, and less ability to avoid hazards than do adults. Exposure to hazardous substances can cause growth and development problems in children, such as learning disabilities, mental retardation, cerebral palsy, and hyperactive airways, as well as cancer.
Recognizing these special vulnerabilities, ATSDR in 1996 launched an initiative to emphasize child health in all agency programs and activities. The Child Health Initiative was introduced by ATSDR's Assistant Administrator Barry L. Johnson, Ph.D., to ATSDR's external Board of Scientific Counselors, in response to direct calls by both the Department of Health and Human Services and EPA for policies that promote child health. A multidisciplinary Child Health Workgroup was appointed by the Board to help ATSDR determine (1) what to do with the existing body of knowledge, (2) where are the key information gaps, and (3) where are the best opportunities for coordination with other agencies and nongovernment organizations. The workgroup has prepared this report to recommend actions and major directions to be undertaken by ATSDR; these recommendations may also be useful to other agencies and organizations.
Developing human beings in the womb and through puberty can be uniquely vulnerable to environmental toxicants, depending on the substance and the exposure situation. There are several reasons for this different susceptibility.
Before birth, children are forming the body organs that need to last a lifetime (Landrigan and Carlson 1995). This is the time when chemical injury leads to its greatest effects. Injury during this period of growth may lead to malformation (teratogenesis) of organs and disruption of function, and premature death. Exposure occurs via the placenta; exposure of the mother usually leads to exposure of the child.
After birth, children may have greater exposures to environmental toxicants than adults. Pound for pound of body weight, children drink more water, eat more food, and breathe more air than adults. For example, children in the first 6 months of life drink 7 times as much water per pound as average American adults. Children 1 through 5 years of age eat 3 to 4 (or more) times as much food per pound body weight as average American adults. The air intake of a resting infant is twice that of an adult. Two characteristics of children further magnify their exposures to toxicants in the environment: (1) their typical hand-to-mouth behavior, which increases their ingestion of any toxicants in dust or soil, and (2) their play activities close to the ground, which increase their exposure to toxicants in dust and soil as well as to any toxicants that form low-lying layers in the air, such as certain pesticide vapors. The obvious implication for environmental health is that children will have substantially greater exposures than adults to any toxicants that are present in water, food, or air. This fact has been demonstrated very clearly in the case of children's exposures to pesticides in the diet.
Other exposure pathways, while not unique to childhood, may affect the child unexpectedly and excessively. For example, children may be exposed to hazardous materials from workplaces by the unknowing or unwise transfer of workplace materials to the home (NIOSH 1995a). In addition, child labor restrictions typically address safety hazards but not hazards posed by toxic substances. Children's main occupation is attending school, and school buildings may pose toxic hazards by virtue of location or construction.
Children's metabolic pathways, especially before birth and in the first months after birth, are immature compared to those of adults. The ability of children to metabolize and excrete certain toxicants is different from that of adults. In some instances, children are actually better able than adults to detoxify environmental toxicants. More typically, however, they are less well able than adults to detoxify chemicals and thus are more vulnerable to them.
Children are undergoing rapid growth and development, and their developmental processes may be easily disrupted (Landrigan and Carlson 1995). Many organ systems in young children, the nervous system and the lungs in particular, are undergoing very rapid growth and development in the first months and years of life. Structures are being developed and vital connections established. Indeed, development of the nervous system continues all through childhood. Neither the nervous system nor the lungs are well able to repair any structural damage that is caused by environmental toxicants. Thus, if cells in the developing brain are destroyed by chemicals such as lead, mercury, or solvents, or if the formation of vital connections between cells is blocked, there is a high risk that the resulting neurobehavioral dysfunction will be permanent and irreversible.
The endocrine system that regulates many functions in the body including growth, sexual maturation, and homeostasis, may be an important target for toxicants. Adolescents often enter the workforce at the lowest levels, where chemical exposures are probable (American Academy of Pediatrics 1995; NIOSH 1994, 1995b, 1996). Long-term studies of this population are notably lacking.
The immune system can have long-lasting alterations after perinatal exposure to environmental toxicants. Besides changing the response to infection, such alterations can also affect the regulation of the development of other systems such as the nervous and reproductive systems (Birnbaum 1995).
Because most children have more future years of life than adults, they have more time to develop chronic diseases triggered by early environmental exposures. Many diseases that are triggered by toxicants in the environment develop decades after the exposure. Examples include lung cancer and malignant mesothelioma caused by exposure to asbestos; leukemia caused by benzene; breast cancer that might be caused by DDT; cardiovascular disease and diabetes related to nutritional alterations; and certain chronic neurologic diseases, such as dementia and Parkinson's disease, that might be caused by exposures to environmental neurotoxicants. Many of those diseases are now thought to be the products of multistage processes within the body's cells that require many years to progress from earliest initiation to actual manifestation of illness. Consequently, certain carcinogenic and toxic exposures sustained early in life appear more likely to lead to disease than the same exposures encountered later in life.
In addition to the thousands of chemicals already in use, hundreds of new chemicals are developed every year and released into the environment. Thus, the extent of children's exposure to synthetic chemicals will almost certainly continue to increase. The toxic effects of most of these chemicals on children, particularly long-term effects, are largely unknown. The problem is not going away. The challenge, therefore, is to understand the unique risks to children from environmental toxicants acting singly or in combination. Only with this knowledge can our society ensure children that they can grow, develop, and reach maturity without excess risk of birth defects, neurologic impairment, developmental disabilities, immune dysfunction, reproductive damage, cancer, or premature death being associated with their environmental exposures.
All children are completely dependent on adults for housing decisions, access to medical care, education, and most risk management decisions. Adults, and the institutions they create, have an obligation to make ethical, responsible, and forward-thinking decisions on behalf of the children of today and tomorrow.
THE IMPERATIVE OF PROGRAMS FOR
CHILDREN'S ENVIRONMENTAL HEALTH
Environmental toxicants are a persistent, growing cause of preventable illness in children. Knowledge about this group of illnesses is also growing (Goldman 1995). That we must anticipate the occurrence of these illnesses is a challenge; that we can prevent or mitigate these illnesses makes such actions an imperative. ATSDR has asked the workgroup for guidance in focusing its actions. Some compelling problems are listed here as examples of these challenges; there are other important topics not listed here, such as environmental tobacco smoke and asbestos.
Benzene
Benzene exposure causes acute myelogenous leukemia. The dose and duration of exposure
needed to cause this cancer is unknown. However, exposure beginning in childhood results in longer
times to be exposed and a longer time to develop the cancer. This is an example of an exposure with
latent effects, that is, exposure in childhood may lead to the development of disease in adult life.
Lead
According to the Centers for Disease Control and Prevention (CDC), 930,000 children in the
United States in 1990 had whole blood lead levels over 10 æg/dL (CDC 1997), which are levels that put
their intellectual development at risk. Lead exposure during childhood has recently been linked
with adolescent aggressive behavior problems (Needleman 1996). After the public health success of
removing lead from gasoline, house paint, and food cans, the main exposure now comes from
existing paint in older houses. Lead exposure of children also continues from industrial facilities,
via the effluent from plants or the clothes of workers.
Mercury
Pollution with metallic mercury leads to the production of methylmercury in the environment.
Methylmercury may bioaccumulate in the food chain. Ingestion of contaminated fish by pregnant
women may led to cerebral palsy and severe mental retardation, as occurred in Minimata, Japan.
Other prenatal exposures have led to neurodevelopmental delays and seizures (Koos and Longo
1976; Amler et al. 1996a).
Nitrates and Nitrites
These agricultural chemicals continue to cause contamination of water supplies (Johnson and
Kross 1990). Nitrites will cause methemoglobinemia when the amount ingested exceeds the individual's
detoxification capacity. Children not only drink more per pound body weight but, particularly in
the first year of life, also have a limited capacity for detoxification. All standards for assessment of
these chemicals must be made on the basis of data for the infant and child.
Pesticides
Children can be exposed to pesticides by direct contact, by inhalation, and through their food,
including breast milk. The National Research Council estimates that 50% of all the pesticides a
person ingests in a lifetime is ingested in the first five years of life (NRC 1993). Some foods
contain enough pesticides that, if prepared for children, they can contain a nearly toxic dose. Several
pesticides are hormone disruptors in animals. The long-term effects of pesticides on the
development of children and adolescents have not been studied adequately.
Polychlorinated Biphenyls (PCBs)
In the Great Lakes region of the United States, children are exposed to polychlorinated biphenyls
(PCBs) in utero and during childhood, by the ingestion of sport fish (ATSDR 1990, 1994a).
Several studies have shown that children exposed to PCBs and other contaminants have lower IQs than
children not eating fish caught in the region (Jacobson and Jacobson 1996).
Trichloroethylene (TCE)
Early exposure to trichloroethylene (TCE) is associated with reports of hearing loss and delays in
speech development (ATSDR 1995a; Burg et al. 1995).
Triggers of Asthma
The doubling of the death rate from asthma in U.S. children since 1980 has been documented by
the CDC (1996a). Environmental pollutants are major contributors to asthma, the most common
admission diagnosis in many children's hospitals. The impact of these trends on health and health
care resources is great. Asthma is caused or triggered by environmental tobacco smoke, ozone
from smog, and particulates in the air. Cockroaches, house-dust mites, pollens, and molds are major
asthma-triggering antigens affecting the pediatric population.
Hazardous Waste Sites
Uncontrolled hazardous waste sites are prevalent throughout the United States. The U.S. Environmental Protection Agency (EPA), in 1996, listed approximately 15,000 sites in the United States; 1,371 were proposed or listed on the National Priorities List (NPL) on the basis of a hazard ranking system. Each of the 50 states has at least 1 NPL site; 5 states (California, Michigan, New Jersey, New York, and Pennsylvania) contain 37% of all the sites and 30% of the children ó17 years of age in the United States. Approximately 11 million people, of whom 25% to 35% are children ó17 years, live within 1 mile of an NPL site (ATSDR 1996b). African Americans, Native Americans, and people of Hispanic origins comprise a greater proportion of these communities than those outside the waste site areas (Heitgerd et al. 1995). The potential adverse human health impact of hazardous waste sites is a considerable source of concern to the general public as well as health professionals and government agencies.
The majority (65% 70%) of uncontrolled hazardous waste sites in the United States are waste storage/treatment facilities (including landfills) or former industrial properties (ATSDR 1996b). Many of these properties have been abandoned, and most have more than one major chemical contaminant. Less common are waste recycling facilities and mining sites, which may be active, inactive, or abandoned. Another group of hazardous waste sites is associated with federal government facilities, such as military facilities and nuclear energy complexes. The National Research Council has cited 17,482 contaminated sites at 1,855 military installations and 3,700 sites at 500 nuclear facilities. Some of these sites cover large geographic areas and are contaminated with very complex mixtures of wastes. The substances most commonly released into environmental media (for example, air or groundwater) from uncontrolled hazardous waste sites are heavy metals and organic solvents: lead (59% of sites), trichloroethylene (53%), chromium (47%), benzene (46%), and arsenic (45%) .
When EPA places a site on the NPL, the Comprehensive Environmental Response, Compensation, and Liability Act, (commonly called the Superfund Act, passed in 1980 and amended in 1986) provides monies for remediation (cleanup) of the site and an array of public health actions in nearby communities (Johnson 1995). ATSDR conducts public health assessments to evaluate the potential health hazards faced by communities in proximity to every proposed, listed, or former NPL site. In many cases this work is conducted by state health departments under ATSDR sponsorship and review. A site is assigned a hazard category according the human health hazard it poses, on the basis of professional judgement and weight-of-evidence criteria. In the 3-year period 1993 1995, this process identified a health hazard at 49% of sites and an urgent hazard at 4%of sites (ATSDR 1996b). It is important to note that a site-specific epidemiologic or other investigation is needed to establish the actual hazard to health. Of the public health assessments conducted to date at 1,371 sites, about 60% have included recommendations that address the need for intervention to interrupt ongoing exposure pathways. These interventions have included provision of alternative drinking water, issuance of fish consumption advisories, posting of warning notices, restrictions of site access, and (rarely) relocation of community residents.
ATSDR'S PUBLIC HEALTH PROGRAMS
ATSDR conducts health consultations and issues public health advisories when site conditions warrant, and maintains surveillance systems and registries of people exposed to a particular substance, to aid in assessing the health consequences of low-level, long-term exposure to hazardous substances. Substance-specific activities include ATSDR's Toxicological Profile series, which summarizes data on the health effects of certain hazardous substances, identifies significant gaps in knowledge, and sponsors applied research to help close those gaps (ATSDR 1994a, DeRosa et al. 1995). ATSDR also maintains a publicly accessible inventory of hazardous substances and a list of sites that are closed to the public or have restricted access because of hazardous substance contamination. ATSDR also provides health-related support to state and local agencies during emergency responses to accidental releases of hazardous substances (ATSDR 1995a).
ATSDR also conducts public health promotion activities in communities concerned about health effects related to emissions of toxic substances from hazardous waste sites. ATSDR's health promotion program integrates the following key components: environmental medicine, risk communication, health education, and public health infrastructure (ATSDR 1994b). In particular, ATSDR works to serve communities in collaboration with a variety of (1) government partners, such as federal, state, tribal, and local health and environmental agencies; and (2) nongovernment partners, such as professional associations, public health organizations, voluntary organizations, and advocates for children and the environment.
ATSDR has demonstrated capabilities and experience in working with numerous at-risk American communities to create site-specific health education plans. Such plans provide residents, and their health care providers, with the information they need to make important choices that can reduce toxic exposures and promote health for themselves and their children. For example, ATSDR created a project with the Ozark Area Girl Scout Council in which Girl Scouts can earn a badge for community health education reports on the health risks of extensive mine waste contamination in the area.
Health care providers have a particular need for authoritative information on the health hazards posed by waste sites and uncontrolled chemical releases. ATSDR currently supports cooperative agreements with several national health professional organizations to assist in providing environmental health education and training for their memberships and constituents. Activities have been expanded to include educational outreach to schools, public safety personnel, local community groups, and public libraries. Many such programs are based on existing technical guidance materials, such as the popular Case Studies in Environmental Medicine series.
THE IMPACT OF ATSDR'S PROGRAMS ON CHILDREN
ATSDR's interest in preventing toxic exposures and promoting the health of children can be traced to its earliest community health investigations and to certain key reports, such as the 1988 document The Nature and Extent of Lead Poisoning in Children in the United States: A Report to Congress (ATSDR 1988a).The following examples of peer-reviewed work in this area were conducted or supported by ATSDR:
As noted previously, ATSDR's Child Health Initiative was introduced in 1996 by ATSDR's Assistant Administrator Barry L. Johnson, Ph.D. to emphasize child health in all agency programs and activities. ATSDR's external Board of Scientific Counselors, appointed a multidisciplinary Child Health Workgroup to help ATSDR determine (1) what to do with the existing body of knowledge, (2) where are the key information gaps, and (3) where are the best opportunities for coordination with other agencies and nongovernment organizations.
The workgroup reviewed existing data on environmental hazards to child health. This body of data has been previously reviewed and several recent reviews are recommended to the reader (see Bibliography). The workgroup also reviewed the four divisions of ATSDR separately. This review included reading published goals and objectives for each division, recent annual reports, and many of the publications from each division. Activities particularly focused on children were reviewed carefully. A meeting was held between members of the workgroup and the leadership of each division. The workgroup also reviewed opportunities to expand and amplify ATSDR's activities through collaboration with other government agencies and through partnerships with several key nongovernment organizations.
During the work period ATSDR staff developed a review of all activities with unique emphasis on children, and compiled the ATSDR Children and Youth Health Activities Inventory, which is available as a complementary document to this report. No comprehensive review or synthesis of this material was intended. However, individual comments were made as appropriate, in the review that follows, on the use of this existing body of knowledge and the efforts to expand these data.
The workgroup recommendations are discussed in three sections. Common ideas arose from the workgroup's reviews of ATSDR's four divisions, and these are stated in the section entitled "Agencywide Recommendations." They apply to all programs of the agency. The section entitled "Divisional Reports and Recommendations" contains reviews of the four divisions with recommendations for the specific programs. An appendix to this report contains the divisions' responses to an early draft of the recommendations that show the rapid incorporation of ideas into division practices.
1. ATSDR should enlarge its scope to include, in explicit and structured ways,
issues of child health in all activities of the agency. Specific guidelines and
procedures need to be formulated around exposure and health issues for children
before birth and at all ages, and added to policies at all levels.
2. ATSDR should review its vision, mission, and goal statements in light of the
Child Health Initiative to see if children should be explicitly included. The
workgroup has proposed the inclusion of language such as the following:
Program
4. ATSDR should require that all its activities be reviewed to ensure the inclusion of child health issues. At each stage of approval, each proposed activity needs division- or agency-level review that might include appropriate child-oriented questions.
5. All of ATSDR's public outreach activities need to be fully studied with respect to the ethical ramifications for children. The unique position of children in informed consent is but one aspect. The agency should devote careful attention to the ethical problems that arise when the care and study of children is not optimal but the agency must conduct health assessments.
Collaboration
6. ATSDR should ensure the widest collaboration among agencies on children's environmental health issues by developing review and discussion at the highest levels. Many organizations and agencies are working on children's environmental health issues. To prevent redundancy, excessive demands on scientific and social leaders, and to provide the greatest total impact, oversight coordination and communication are necessary between as many of these groups as possible.
Education
7. ATSDR should build expertise in children's environmental health issues through education of the following groups :
Division of Toxicology
Prepared by Lorne K. Garrettson, M.D., and Gershon H. Bergeisen, M.D., M.P.H.
The mission of the Division of Toxicology (DT) is divided into the following three areas:
1. Toxicologic Information. This includes the ATSDR/EPA priority listing of chemicals,
which identifies topics and ranks them for the agency's study; and the preparation of Toxicological
Profiles on these chemicals. Minimal risk levels (MRLs) for screening purposes are developed
during this process.
2. Research Program. This includes the identification of priority data needs and the
implementation of a substance-specific applied research program, and the latter includes the Great
Lakes Human Health Effects Research Program.
3. Emergency Response and Substance-Specific Health Consultations. This includes
24-hour availability of expert multidisciplinary consultations on the extent of danger to public
health
from a release or threatened release of a hazardous substance.
Toxicologic Information
The Priority Listing is a list of 275 substances found at National Priorities List (NPL) sites and
believed to be most hazardous to human health. This listing of chemicals helps form ATSDR
priorities on many issues. It is reexamined each year because new sites are routinely added to the
NPL, new data about how people might be exposed become available as public health assessments
are completed, and important new toxicity information about a substance might become available.
The listing needs no specific identification of special data needs for children.
The Toxicological Profiles series is a very complete series of review-analysis documents on the
chemicals on the Priority Listing. The profiles help environmental and health professionals
throughout the United States and the world to identify and characterize hazards, assess exposure,
and characterize risk. There are no specific sections on children. However, the chapters on health
effects always include a section on reproductive effects that deals with developmental effects
through intrauterine implantation. Also, a section on developmental effects contains information
on
fetal effects and development through sexual maturity in animals and humans. Data are given on
known effects on growth and development, and these data cover the childhood years.
Children are included in the Toxicological Profiles in several ways. In the chapter on health
effects, infants and children are sometimes included in the section on populations that are considered
"unusually susceptible." There is a section on toxicokinetics that may provide data, when
available, on children and young animals. In the chapters on potential for human exposure, children may be
discussed under populations with "potentially high exposures." In all such chapters, discussions
are driven by the availability of data. In the chapters on health effects, potential for human exposure,
and often in the chapter on analytical methods, there is a section on adequacy of the database
which identifies data needs. Children are often included in this section, and the leadership of DT sees this
as a high priority.
The MRL is an estimate of the daily human exposure to a substance that is likely to be without an
appreciable risk of adverse, noncancer health effects over a specified duration of time. The
development of MRLs is done after the review required to compile the Toxicological Profiles.
These numerical criteria, used for screening, are set to include acute, subacute and chronic exposures.
Special groups, including infants and children may be considered in determining an MRL. When
dealing with infants, the usual factors in the derivation of an MRL may be changed to consider
age effects. Many such guidelines are based upon experimental animal studies because human data are
often unavailable, particularly for chronic, low dose exposures. In addition, human data are often
inadequate to establish a dose-response relationship. Thus, these environmental guidelines do not
always reflect special sensitivities or particular vulnerabilities of children, pregnant women, or, for
that matter, the old or the ill.
Examples of the need to systematically focus on children can be found in current documents. In
the case of mercury, no factor for human variability was used to effect a more protective acute
inhalation MRL because the MRL was based on exposure of rats during postpartum days 11
through 17, and these immature rats were considered a sensitive population. In contrast, in the case of
pentachlorophenol, the data driving the determination used were from rat pups that were exposed
during gestational days 6 through 15. In this case, the developing fetus was not considered a
sensitive population and an uncertainty factor for human variability was applied. No attempt has
been made to review all Toxicological Profiles. However, DT has used childhood data frequently
and creatively.
Research Program
The development of priority data needs starts with the identified needs noted in the Toxicological
Profiles. The agency works with the National Toxicology Program and the EPA Office of
Pollution, Prevention, and Toxics to develop the sections on data needs. The National Institute of
Environmental Health Sciences (NIEHS) and the EPA are collaborators in the prioritization of
data needs for the priority data needs statement. No specific procedure or structure is used to focus on
children's needs.
The Substance-Specific Applied Research Program (SSARP) initiates programs to fill in
the gaps in information identified in the priority needs activities mentioned above. The agency
works with other governmental agencies, private sector research programs, and the Minority Health
Professions Foundation Research Program to meet this goal. Some identified needs (21) have led
to rule-making by the EPA.
Under this program, the largest study has had a substantial focus on child health. This is the Great
Lakes Human Health Effects Research Program. In addition, a long-term study of the perinatal
effects of lead has been conducted. An animal study of multigenerational effects of mercury and
zinc began in 1992. A private sector group is studying reproductive and developmental effects of vinyl
chloride. Two reviews of environmental contaminants in human breast milk have been written and
submitted. In 1988, ATSDR prepared a report to Congress on the nature and extent of childhood
lead poisoning in the United States. The thread of this activity continues in the attempts to
develop MRLs for lead. This effort has been presented at scientific meetings for review and is continuing.
Since 1988, ATSDR has maintained an interagency agreement (IAG) with the National
Toxicology Program, which focuses on modeling and computation to study the toxicology of substances
identified at NPL sites. The evaluation of physiologically based pharmacokinetic modeling by DT
may have relevance for developmental toxicology in children, as this approach may better define
differences that occur in the distribution of certain compounds during development. There is no
specific statement regarding children in this IAG.
Emergency Response and Substance-Specific Consultations
Many of DT's responses to emergencies and requests for consultation have dealt with children.
There are between 6 and 12 consultations from schools each year. Of the more than 100
emergency requests yearly, children are well represented. There have been sufficient numbers of calls about elemental mercury exposure in children that a descriptive article of DT's cases has been published.
MRLs that have taken child risk into account have been useful in these activities.
DT publishes a three-part basic text on the management of acute medical emergencies entitled
Managing Hazardous Materials Incidents. This set is widely distributed. No one on the editorial
boards of these volumes is uniquely trained in emergency pediatrics. There is no section in these
volumes that addresses unique needs of the infant or child.
Comments
DT has no written goals or objectives that deal specifically with child health issues. However,
discussion with the DT leadership indicated that reproductive and developmental toxicology are
agencywide interests and the leadership is "never satisfied" until these areas of concern have been
addressed; these topics are systematically included. Children, when data are available, are covered
in the section on developmental effects. All activities of DT show a pervasive interest and
sensitivity to the unique needs of children, and several areas of DT's activity are focused specifically on
children. Fundamental research tools have been developed that are uniquely beneficial to the study
of children.
Recommendations
Much of DT activity is centered around the Toxicological Profiles. Through this study comes the
development of the priority data needs list and the development of MRLs. Because these three
activities have the broadest impact, it is in these areas of activity that attention on children should
be focused.
Expansion of child health issues in the Toxicological Profiles could be accomplished in two ways.
In each toxicological profile, add: (1) a separate section in the chapters on health effects and
potential for human exposure to ensure that data on children or the young are highlighted, or (2)
use an algorithm for questioning each section.
For the second approach, an algorithm would ask several questions such as the following:
Are children exposed to the toxicant in question or to similar toxicants?
Are unique exposure pathways for children known or possible?
Are children different in their weight-adjusted intake of the toxicant?
Are pharmacokinetic/pharmacodynamic parameters known or suspected to be
different in children?
Could the developmental process be altered by the toxicant?
The advantage of such an algorithm would be, firstly, that such information would not be
overlooked in the Toxicological Profile. But, secondly and possibly of more importance, the questions might
lead to the identification of unique child-oriented priority data needs. Thirdly, such considerations
might identify questions to be brought to the focus of setting MRLs.
The structured approach to the pediatric issue seems to be of particular benefit in a group of
scientists who are already focused on developmental issues. A first approach would be to refine
the algorithm with input from all branches of DT and from those in other divisions.
DT should add pediatrics-trained emergency medical personnel to the boards that oversee the
development of the volumes on emergency management. The specific needs of infants and
children should be covered in future editions. Latent or chronic effects of pediatric exposures should be
mentioned.
Division of Health Assessment and Consultation
Prepared by Philip J. Landrigan, M.D., M.Sc., and Carole A. Kimmel, Ph.D.
The mission of the Division of Health Assessment and Consultation (DHAC) is composed of the
following responsibilities:
1. Complete public health assessments of all sites on the NPL within 1 year of the date
they are proposed for addition.
2. Address petitions for public health assessments.
3. Provide consultation on health issues related to exposure to hazardous or toxic
substances and, upon request, provide consultation, on the basis of available
information, to the administrator of EPA and to state and local officials on health
issues related to exposure to hazardous or toxic substances.
4. Determine the extent of danger to public health from a release or threatened release
of a hazardous substance.
5. Conduct public health assessments of landfills or surface impoundments that pose
a substantial potential risk to human health because of the existence or release of
hazardous substances, the magnitude of contamination with hazardous substances
that may be the result of a release, or the magnitude of the population exposed to
such release or contamination.
Since 1987, ATSDR has conducted 1,571 public health assessments, including petitioned health
assessments at 167 NPL sites. Much of what the agency has learned about the nature and extent
of exposures to releases of contaminants from hazardous waste sites comes from the accumulated
findings of hundreds of public health assessments prepared by ATSDR and many state health
departments. Findings from ATSDR's public health assessments have been compiled into one
comprehensive database, HazDat.
The public health assessment represents a considerable effort to identify and characterize a
completed exposure pathway. An exposure pathway is the process by which a person is exposed
to contaminants that originate from some point source, such as a hazardous waste site or
accidental spill or release of chemical substances. The mere presence of a contaminated medium
does not confirm a completed exposure pathway. For any person thought to be exposed it is
important to determine the amount, route, duration, and frequency of exposure to each
contaminant because all of these factors influence the likelihood of adverse health effects. A
completed exposure pathway consists of all of the following five elements, which may have
occurred in the past, are occurring in the present, or may occur in the future:
1. Source of contamination. The source of contaminant release into the environment can
be a site or facility that is operating, no longer operating, or abandoned; or an accident such as
an explosion, collision, or spill; or other emergency event. Common examples include
incinerators, landfills, emission stacks, and unsanctioned discharges of wastewater. (Sometimes,
when a site contains a longstanding chemically contaminated medium without a clearly known
source, such as an old pit, pond, or lagoon, the medium itself is considered the source.)
2. Environmental medium. The medium transports the contaminant from the source to a
person or persons. Common environmental media include groundwater, surface water, drinking
water, air, surface soil, subsurface soil, sediment, or consumable plants or animals. Each
medium can influence exposure pathways differently. For example, contaminants in air may
travel in a direction and a distance entirely different from the movement of contaminated
groundwater. The environmental fate and transport of each contaminant in different media are
often assessed with extensive sampling, measurement, and modeling.
3. Point of exposure. The point of exposure is the location of possible or actual human
contact with a contaminated medium. Common examples include the home, yard, playground,
campground, body of water, spring, well, or food service. Past, present, and possible future
human activities near a hazardous waste site are important considerations when determining a
person's exposure to hazardous substances. Children, in particular, may ignore or fail to notice
warning signs, find openings in fences, or otherwise gain access to restricted places on or near
a site. Often there is considerable variation with climate, season, and time of day.
4. Route of exposure. The route of exposure is the means by which the contaminant contacts
or enters the body. Common examples are ingestion, inhalation, dermal contact, and dermal
absorption. Dermal exposures are especially active for lipophilic substances, such as PCBs.
Some children display a habit disorder, pica, in which they deliberately ingest soil or other
nonfood matter that might be contaminated. For any route of exposure, the duration and
frequency should be considered in assessing a completed exposure pathway.
5. Receptor population. The receptor population is the group of people who live in a setting
that is likely to lead to contact with the exposure pathway. Common examples include children
who use a playground with contaminated soil, families who drink water from wells drawing
groundwater from a contaminated aquifer, and anglers who catch and eat contaminated fish.
Each contaminated medium or point of exposure can affect different receptor populations,
depending on differences in wind and water direction, human activities and cultures, and
historical changes.
The workgroup recognized that DHAC already does a substantial amount of child-focused health
assessment in the course of all these field activities.
Recommendations
To respond consistently to the heightened vulnerability of children, DHAC field staff need
specifically to consider children in each of the components of a health assessment at each
hazardous waste site:
Environmental characterization data
Community health concerns
Health outcome data
To be successful in this endeavor, DHAC staff should consider ways to refocus the current
paradigm for health assessment, which places the toxicant or hazard at the center of the discussion;
examines known data on effects, routes of exposure, and mechanisms of action; and from this analysis,
develops information for further study and/or remediation. But, what if children, not the toxicant,
were placed at the center of the paradigm? A host of different questions would be asked:
To what is the child exposed?
How is the child exposed and at what stage of development?
Are these exposures of particular concern for children on the basis of available data?
What are the effects of acute exposures or long-term, low-level exposures?
What are the delayed effects?
What are the effects of multiple and cumulative exposures?
What are the transgenerational effects?
Are children more or less sensitive than adults?
What additional information/research is needed to adequately characterize children's
health concerns?
Using this paradigm, data would need to be collected and analyzed on the basis of children's
exposures, not extrapolated from adult data.
Division of Health Studies
Prepared by Cynthia F. Bearer, M.D., Ph.D., and David Bellinger, Ph.D., D.Sc.
The mission of the Division of Health Studies (DHS) has the following five elements:
1. Conduct periodic surveys and screening programs to determine relationships between
exposure to toxic substances and health.
2. Conduct pilot studies of the health effects of toxic substances for selected groups of
exposed individuals to determine the desirability of conducting full-scale
epidemiologic or other health studies.
3. Conduct epidemiologic studies designed to evaluate the causal nature of associations
between exposure to hazardous substances and disease outcome by testing scientific
hypotheses.
4. Conduct health surveillance programs of exposed populations (including medical
testing and referral for treatment).
5. Establish and maintain national registries of (a) persons exposed to hazardous
substances and (b) persons with serious diseases or illness.
ATSDR evaluates the following seven priority health conditions (Lybarger et al. 1993) in
populations living or working near hazardous waste sites (in alphabetical order):
» Birth defects and reproductive disorders
» Cancer (selected anatomic sites)
» Immune function disorders
» Kidney dysfunction
» Liver dysfunction
» Lung and respiratory diseases
» Neurotoxic disorders
A variety of adverse health effects have been reported in investigations of communities around
different hazardous waste sites. These effects have ranged from nonspecific symptoms such as
headache, fatigue, and irritative symptoms, to specific conditions such as low birthweight,
congenital heart defects, and neurobehavioral deficits. Most investigations have included some
children in the study population, but in only a few cases have effects on children served as the
primary focus.
Biological testing can be an effective method to document contaminant exposure and body
burden, and adverse health effects in persons exposed to contaminants from hazardous waste
sites. Assessment methods range from biomarkers of exposure, such as assay of blood lead
levels and compounds in body fat biopsies, to biomarkers of effect, such as blood lymphocyte
phenotyping and neurobehavioral testing.
A biomarker of exposure provides a reasonable measure of the internal body dose of a substance
over a period of time that depends on the pharmacokinetics of that substance. Testing is
performed on urine, saliva, hair, blood, breast milk, body fat, or other tissues. Noninvasive
techniques, when available, are preferable for infants and children. Analytical methods and
human reference ranges are available for many of the substances found most commonly at
hazardous waste sites. In many cases, age-specific reference ranges are also available to facilitate
interpretation of levels found in infants and children.
DHS has developed standardized test batteries for subclinical and clinical organ damage or
dysfunction related to the five priority health conditions other than cancer and birth defects. The
test batteries used most commonly are basic screening panels that can evaluate hundreds of
people at a time and help detect early dysfunction of organ systems in concert with other
diagnostic modalities. Many of the component tests are well-validated and commonly used by
health care providers and health researchers for diagnosis and evaluation of individual patients.
A focused panel is often available for in-depth evaluation to follow up well-defined exposures
or results obtained from a basic test battery.
The special considerations required for addressing the health needs of children are acknowledged
in different ways in the various batteries. The pediatric environmental neurobehavioral test battery
(PENTB) (Amler and Gibertini 1996; Amler et al. 1996b) is the pediatric equivalent of the adult
environmental neurobehavioral test battery (Amler et al. 1995). The battery for assessing lung and
respiratory diseases (Metcalf et al. 1994) describes standardized methods for use with infants and
children. The basic immune test battery (BITB) (Straight et al. 1994) does not include a separate
battery of tests for children because basic immune functions and mechanisms are similar in adults
and children. A need is recognized, however, for valid reference ranges for children and for more
sensitive biomarkers of subclinical toxicant exposure in children because of changes with age in
the distribution of many components of the immune system.
Recommendations
General Comments. The development and systematic usage of clear, concise and
comprehensive policies and procedures would facilitate the incorporation of children into
child-centered ATSDR health studies and the National Exposure Registry. Within these
formalized procedures, children's concerns could and should be systematically incorporated.
At each decision point, the unique susceptibilities, exposures and vulnerabilities of children should
be considered (see the questions in the section on Agencywide Recommendations under point 3).
Pediatric expertise should be represented at each stage of the internal and external review process
and at each decision point with respect to policies and procedures.
Health Studies. Although child-specific issues are often considered in the design and conduct
of health studies, the document describing the process used by DHS in considering whether to
conduct a health study and which type would be appropriate could be made more specific to
ensure that child-specific issues are addressed. Assessment of a site, for instance, includes consideration
of whether there is evidence of completed pathways of exposure. Since pathways may differ
between children and adults for certain compounds (for example, lead), this assessment should
include specific consideration of this possibility. The criteria used to determine the type of health
study that would be appropriate at a particular site includes "...documented evidence of human
exposure at a level of concern." Because of the greater susceptibility of children to many
chemicals, the decision process should acknowledge that the "action level" may be lower for children than for adults.
All study protocols, whether they originate internally, from a state department of public health, or
a university-based investigator, should include a statement discussing how the proposed research
addresses child health issues in the target population or justifying why this would not be
appropriate or necessary given the target population. This requirement would be analogous to those imposed by the "NIH Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical Research" (US DHHS 1994).
Although many instruments are available for the assessment of exposure, the refinement of the
battery for immune function in children and the development of age-specific reference ranges
should be considered. The development of more sensitive biomarkers in children for subclinical toxicant
exposures should always be an objective.
Pediatric expertise should be represented at each stage of the internal and external peer review
process, including preliminary proposals and all review steps to final clearance. At present, the
review of study protocols and reports appears to be more oriented toward occupational and
environmental health issues rather than pediatric issues. The recruitment of additional personnel
with pediatric expertise is recommended.
National Exposure Registry Program (Health Endpoints). It is appropriate to use disease
rates in nationally representative reference groups (for example, National Health Interview Survey
[NHIS], the National Cancer Institute's SEER) to determine whether members of a subregistry
have an excess of one or more adverse health conditions. As the divisional policies and procedures
manual notes, identifying an appropriate site-specific (nonexposed) comparison group is usually
not feasible for both scientific and logistical reasons. This strategy does require, however, that the
range of health conditions that can be examined are limited to those contained in the available reference
databases. These conditions tend to be long-term health effects confirmed by medical diagnosis.
Specifically, pediatric diseases are somewhat underrepresented, although the list includes mental
retardation and speech impairment. Asthma is included in a category with emphysema and chronic
bronchitis. The list of categories for primary site of cancer does not include central nervous
system (CNS) tumors (for example, neuroblastoma, the second most common form of childhood cancer).
The development of a pediatric-specific list of priority health conditions would assist in focusing
studies on children. This task should be coordinated with the child-oriented priority data needs
developed by the Division of Toxicology.
In order to provide the opportunity to examine a broader range of health endpoints, other
databases [on the local, county, or statewide level) might be identified that provide the necessary
comparative data. Use of such databases would address the stated purpose of most subregistry analyses, which is to generate rather than to test hypotheses. The prevalence data available in such databases may even be more appropriate than NHIS data for the comparisons of interest in the site-specific
population. This strategy would be easier to implement for subregistries that include individuals at
only a small number of sites (for example, benzene) rather than many sites (for example, TCE).
National Exposure Registry Program (Analyses of Disease Rates in Subregistry
Populations). The size of the available child population should be a major criterion in selecting
a site for a subregistry, especially for those exposures to which children are known to be
substantially more susceptible than are adults. Analyses should incorporate smaller age strata. In
analyses of the benzene subregistry, for example, the 0 9- and 10 17-year-old groups were
combined due to sparse data. The resulting 0 17-year-age stratum is likely to be too broad to
capture certain exposure-disease relationships. Special attention should be given to including a sufficient
number of sites in a subregistry to make it possible to examine disease rates in narrow age strata
within childhood, with large enough numbers in each stratum to provide an estimate with a
relatively precise confidence interval. It may be appropriate for some exposures to establish a subregistry
that focuses specifically on the child population rather than the entire age range.
Division of Health Education and Promotion
Prepared by Joy Carlson, M.P.H., and Joan M. Cranmer, Ph.D.
The Division of Health Education and Promotion (DHEP, formerly the Division of Health
Education) is mandated to assemble, develop as necessary, and distribute to the states, and upon
request to medical colleges, physicians, and other health professionals, appropriate educational
materials (including short courses) on the medical surveillance, screening, and methods of
diagnosis and treatment of injury or disease related to exposure to hazardous substances.
This division is undergoing an extensive reorganization and expansion of its role in educating the
public and the health care community about hazardous waste sites, environmental contaminants,
and their implications for human health risk. Because of this reorganization, DHEP has a clear
opportunity to incorporate a child health focus into its mission, functional statement, structure,
programs, and activities. Additional language might be added to strengthen DHEP's focus on child
health as a priority in areas of health education, health risk communication, and health promotion.
The workgroup reviewers thought that the current reorganization of DHEP was sufficiently
comprehensive in scope that a section-by-section review of DHEP along the lines of its earlier
setting would not be meaningful for future planning.
Recommendations
Mission and Goals. DHEP should incorporate children and infants into its mission, goals, and
practice. As noted previously, this is an ideal time to do so, given the reorganization that is under
way. Professional organizations that are funded under current mechanisms should be encouraged
to add pediatric environmental health training and expertise. Some partner organizations are
already doing so. All future ATSDR announcements for cooperative agreements and other funding
mechanisms for health education and promotion might incorporate children as a focus for activity
and attention. Existing protocols should be reviewed and, where necessary, guidelines for children
should be included.
Capacity Building and Preparedness. Because there has been little systematic inclusion of
children's environmental health issues, internal expertise on the issue is limited. DHEP should
work with the other divisions to develop a series of clinical practice guidelines in environmental
medicine for children (pediatric environmental health). This task would involve convening experts in
pediatric and environmental medicine to develop batteries of tests to detect adverse health effects in
children who have been exposed to hazardous substances, and to provide clinical practice guidelines for
environmental medicine evaluation for the pediatric age group. ATSDR has already developed
and adopted one such battery to evaluate neurobehavioral disorders, the pediatric environmental
neurobehavioral test battery (PENTB). The following five test batteries are proposed for
development:
1. A general public health assessment template for environmentally exposed children.
2. A module on assessing possible kidney problems in environmentally exposed
children.
3. A module on assessing growth and development in environmentally exposed
children.
4. A module on assessing immune function in environmentally exposed children.
5. A module on assessing growth and pulmonary function in environmentally exposed
children.
In addition, the following recommendations will assist in building such expertise and
understanding within the agency:
Hire staff with pediatric expertise.
Conduct internal training on pediatric environmental health.
Begin to incorporate pediatric environmental health issues into all internal
training, presentations, conferences, and discussions.
Create more partnerships with pediatric environmental health experts.
Require scientists and medical personnel within the agency to attend training sessions
on pediatric environmental health.
With this approach, DHEP can become the internal training center for ATSDR and sponsor
building block training to enhance the knowledge and skill base of all agency personnel. This process will
require multiple stages.
Those who receive grants from the agency should take the following steps:
Provide training in pediatric environmental health.
Contract with organizations that have expertise to provide education and technical
assistance to grantees for the period of time when internal capability is developing.
Increase and enrich relationships with organizations and groups to improve their capacity
to provide pediatric environmental health education.
ATSDR-sponsored training for health professionals traditionally has addressed adult secondary
and tertiary environmental health issues rather than primary prevention issues. Incorporate child health
into the training, and whenever possible, bring in a primary prevention focus. In particular, DHEP
should take the following steps:
Make particular outreach to emergency response personnel in pediatric environmental
health outreach and education efforts.
Work actively with organizations that are developing materials, batteries, etc.
With outside help, develop a general health assessment template for children.When ATSDR has developed a paradigm and supporting procedures for the inclusion of infants and children into its internal activities, it can then begin to use these procedures in its collaborative projects with other federal agencies, state and local governments, and the private sector. It should be the goal to foster an attitude toward the inclusion of child-oriented thinking in all activities. Roles for ATSDR's partner organizations may include the following:
Members of the Child Health Workgroup know that there are many agencies and organizations that are active in children's environmental health. As these recommendations are made, it is recognized that there is now a need for coordination and collaboration of efforts in this critical area. The government needs an institutional focal point to provide this function for children's environmental health.
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Neonatal behavioral assessment scale performance in humans influenced by maternal consumption of environmentally contaminated Lake Ontario fish. J Great Lakes Res 22(2):198-212. Lybarger JA, Spengler RF, DeRosa CT. 1993. Priority health conditions: an integrated approach to evaluate the relationship between illness and exposure to hazardous substances. Atlanta: US Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry, July. Metcalf SW, Samet J, Hanrahan J, Schwartz D, Hunninghake G. 1994. A standardized test battery for lung and respiratory diseases for use in environmental health field studies. Atlanta: US Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry, September. National Committee for Childhood Agricultural Injury Prevention. 1996. Children and agriculture: opportunities for safety and health. Marshfield (WI): Marshfield Clinic. National Institute for Occupational Safety and Health (NIOSH). 1994. NIOSH reproductive hazards in the workplace: bibliography. Cincinnati (OH): US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. National Institute for Occupational Safety and Health (NIOSH). 1995a. Report to Congress on workers' home contamination study conducted under The Workers' Family Protection Act (29 U.S.C. 671a). Cincinnati (OH): US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. September. National Institute for Occupational Safety and Health (NIOSH). 1995b. Request for assistance in preventing deaths and injuries of adolescent workers. Cincinnati (OH): US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. May. National Institute for Occupational Safety and Health (NIOSH). 1996. Work-related injuries and illnesses associated with child labor United States. MMWR Morb Mortal Wkly Rep 45:464-8. National Research Council (NRC), Committee on Pesticides in the Diet of Infants and Children. 1993. Pesticides in the diet of infants and children/Committee on Pesticides in the Diet of Infants and Children, Board on Agriculture and Board on Environmental Studies and Toxicology, Commission on Life Sciences, National Research Council. Washington, DC: National Academy Press. Needleman HL and Landrigan PJ. 1994. Raising children toxic free: how to keep your child safe from lead, asbestos, pesticides, and other environmental hazards. New York: Farrar, Straus and Giroux. Needleman HL, Riess JA, Tobin MJ, Biesecker GE, Greenhouse JB. 1996. Bone lead levels and delinquent behavior. JAMA 275(5); 363-9. New York State Department of Health. 1995a. Final report: exposure to PCBs from hazardous waste among Mohawk women and infants at Akwesasne. Atlanta: US Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry, January. New York State Department of Health. 1995b. Analytic study to evaluate associations between hazardous waste sites and birth defects. Atlanta: US Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry, June. Straight JM, Kipen HM, Vogt RF, Amler RW. 1994. Immune function test batteries for use in environmental health field studies. Atlanta: US Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry, August. Terracciano GJ, Lemasters GK, Amler RW, editors. 1996. Standardized assessment of birth defects and reproductive disorders in environmental health field studies. Atlanta: US Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry, September. United States Department of Health and Human Services (US DHHS). 1994. Notices. DHHS, PHS, NIH. NIH Guidelines on the inclusion of women and minorities as subjects in clinical research, part IV. Federal Register 59(4):11146-11151. March 9. United States Environmental Protection Agency (EPA). 1991. Guidelines for developmental toxicity risk assessment. Final guidelines. Federal Register 56:63798-63826, December 5. United States Environmental Protection Agency (EPA). 1996. Environmental health threats to children. Washington, DC: EPA Doc No. 175-F-96-001, September. Washington State Department of Health. 1994. Mortality study of children residing near ASARCO Copper Smelter in Ruston, Washington. Atlanta: US Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry, December.
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X. Seattle (AK, ID, OR, WA) (206) 553-2113The terms child and children, as used in this document, refer to all aspects of development, including reproductive processes; embryogenesis; fetal development; and all ages of infants, children, and youth to 20 years of age.
Developmental Toxicity
Developmental toxicity implies adverse effects on the development of the child that may result from exposure prior to conception, during prenatal development, or postnatally to the time of sexual maturation. Adverse developmental effects may be detected at any point in the life span of an individual. The major manifestations of developmental toxicity include (1) death (including fetal demise, miscarriage, and stillbirth), (2) structural abnormality, (3) altered growth, (4) functional deficiency (including such things as asthma, mental retardation, learning disabilities), and (5) cancer (modified from EPA, 1991).
Environmental Justice
This working definition was developed by EPA's Office of Environmental Justice. Environmental justice means the fair treatment and meaningful involvement of all people, regardless of race, ethnicity, culture, income, or education level, with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies. Fair treatment means that no population, due to political or economic disempowerment, is forced to shoulder the negative human health and environmental impacts of pollution or other environmental hazards.
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