The CDC blood lead reference value for children: time for a change.

The purpose of this article is to consider alternate uses of the blood lead reference value for children. There are two possible approaches. Historically the reference value has been used to guide clinical and public interventions for individual children. As the distribution of blood lead levels in the population has been lowered over time, the blood lead level at which interventions are recommended has also been reduced. The use of a reference value of 3.5 µg/dL, based on the 98 percentile of blood lead levels for children in 2011-2014 National Health and Nutrition Examination Survey is under review. For several reasons, adopting the new reference value to guide clinical and public health management puts practitioners in an untenable position. First, the changes in the brain caused by lead are significant and persistent. However, these adverse impacts are subtle and although clearly identified at the population level, not predictive for individual children. In addition, the recommended interventions have not been shown to reduce blood lead levels once they are elevated. Finally, clinical laboratory and office-based blood lead testing devices are not required to quantify blood lead levels < 4 µg/dL and in many cases cannot reliably test for low blood lead levels. Revising the reference value also will undoubtedly result in diversion of resources away from those population-based interventions which have demonstrated success. We argue for second approach, in the management of lead poisoning in the US from one of evaluation and management at the individual level to one of population based primary prevention. This would require a strategy directed at controlling or eliminating lead in children's environment before they are exposed. The reference value, as a benchmark, is essential to ensure that primary prevention efforts are successful.

Findings from a pilot environmental health intervention at early childhood centers in the District of Columbia.

BACKGROUND: Children are uniquely susceptible to environmental health exposures that effect developmental delays and negatively impact long-term health outcomes. Despite extensive hours spent at early child care centers, child care providers (CCPs) lack the knowledge to identify and mitigate environmental hazards to the children. METHODS: From 2007 to 2010, we recruited child care centers in the District of Columbia and offered interactive environmental health training to the CCPs. Each center underwent a 90-min environmental health risk assessment (ERA) at baseline and also after the trainings. Dependent t-tests were used to assess the mean change on the ERA score and also the knowledge test administered pre- and post-trainings. Analysis of variance was used to examine the association between knowledge change for the CCPs and the ERA scores of their centers. RESULTS: Of the 60 facilities, 68% reduced their environmental risk. The 585 CCPs who attended the training session showed significant improvement on all items on the test. However, test scores for the CCPs from centers that reduced their risk were not significantly different from the other CCPs. CONCLUSIONS: The trainings increased knowledge on environmental health hazards among CCPs. Areas of significant risk reduction were under the direct control of the CCPs and corresponded to key items on the knowledge test.

Medical education for obstetricians and gynecologists should incorporate environmental health.

Obstetricians-gynecologists can protect the reproductive health of women, men, and their offspring from environmental hazards through preconception and prenatal counseling and encouraging patients to take actions to reduce environmental exposures. Although obstetricians-gynecologists are well positioned to prevent hazardous exposures, education on environmental health in medical education is limited. The Mid-Atlantic Center for Children's Health and the Environment and the Department of Obstetrics and Gynecology of George Washington University convened a meeting to begin integration of environmental health topics into medical education for obstetricians-gynecologists. Several avenues were identified to incorporate environmental health topics into medical education including continuing education requirements, inclusion of environmental health questions on board certification examinations and the creation of a curriculum on environmental health specific to obstetrics-gynecology.

Review of: Ailing in Place: Environmental Inequities and Health Disparities in Appalachia.

The Journal of Appalachian Health is committed to reviewing published media that relates to contemporary concepts affecting the health of Appalachia. The Appalachian environmental inequities and the health disparities we face have a direct effect on our experience of illness. Dr. Jerome Paulson reviews the book Ailing in Place: Environmental Inequities and Health Disparities in Appalachia.

Development of the pediatric environmental health specialty unit network in North America.

Training in environmental health in general, and pediatric environmental health in particular, is inadequate. The Agency for Toxic Substances and Disease Registry began to develop pediatric environmental health specialty units (PEHSUs) after noting the dearth of practitioners who could evaluate and manage children with exposures to environmental health hazards. The Environmental Protection Agency subsequently joined in providing support for what has developed into a network of 13 PEHSUs in North America. PEHSUs provide services to families, act as consultants to clinicians and public agencies, develop educational materials, and respond to natural disasters, including hurricanes and wildfires. PEHSUs are relatively easy to organize and should be replicable internationally.

Building Capacity in Pediatric Environmental Health: The Academic Pediatric Association's Professional Development Program.

BACKGROUND: Environmental exposures contribute to multiple diseases in children; yet, few pediatricians have training in pediatric environmental health (PEH), and few academic health centers have PEH expertise. To build national capacity in PEH, the Academic Pediatric Association (APA) launched a professional development program that since 2002 has encouraged the establishment of post-residency/post-doctoral training programs, supported a special interest group, and convened an annual mentored retreat for PEH trainees. OBJECTIVE: Describe the APA's professional development program in PEH and assess its impact by tracking careers of former trainees. METHODS: Careers were tracked through interviews with trainees and program directors supplemented by searches of institutional websites. Publication listings were obtained through PubMed. Publication impact was assessed using bibliometric and altmetric measures. Grant histories were accessed through the National Institutes of Health RePORTER project. Information on advocacy work was obtained through interviews with program directors. RESULTS: Fifty-five trainees (36 physicians and 19 health scientists) completed PEH training and attended the APA retreat between 2002 and 2017. Forty-one (75%) are pursuing academic careers, 11 are associate or full professors, 11 are practicing general pediatrics or a pediatric subspecialty, 2 are Centers for Disease Control and Prevention epidemiologists, and 1 is a data scientist. Forty-two former trainees (76%) listed "environment" or "environmental" in their job titles or on their websites. Former trainees have published 632 scientific papers. These papers have been cited 3094times, have a relative citation ratio of 2.97, and have been read or viewed 1,274,388times. Twenty-one former trainees have been awarded 43 National Institutes of Health grants. Trainees have developed education and advocacy skills by teaching medical students and residents, presenting grand rounds, preparing policy papers, presenting legislative testimony, and making presentations to public audiences. CONCLUSIONS: The APA's professional development program has contributed to the expansion of national capacity in PEH. Former trainees are populating the field, generating new knowledge, and moving into leadership positions.

Pediatric Considerations Before, During, and After Radiological or Nuclear Emergencies.

Infants, children, and adolescents can be exposed unexpectedly to ionizing radiation from nuclear power plant events, improvised nuclear or radiologic dispersal device explosions, or inappropriate disposal of radiotherapy equipment. Children are likely to experience higher external and internal radiation exposure levels than adults because of their smaller body and organ size and other physiologic characteristics, by picking up contaminated items, and through consumption of contaminated milk or foodstuffs. This policy statement and accompanying technical report update the 2003 American Academy of Pediatrics policy statement on pediatric radiation emergencies by summarizing newer scientific knowledge from studies of the Chernobyl and Fukushima Daiichi nuclear power plant events, use of improvised radiologic dispersal devices, exposures from inappropriate disposal of radiotherapy equipment, and potential health effects from residential proximity to nuclear plants. Policy recommendations are made for providers and governments to improve future responses to these types of events.

Pediatric Considerations Before, During, and After Radiological or Nuclear Emergencies.

Infants, children, and adolescents can be exposed unexpectedly to ionizing radiation from nuclear power plant events, improvised nuclear or radiologic dispersal device explosions, or inappropriate disposal of radiotherapy equipment. Children are likely to experience higher external and internal radiation exposure levels than adults because of their smaller body and organ size and other physiologic characteristics as well as their tendency to pick up contaminated items and consume contaminated milk or foodstuffs. This technical report accompanies the revision of the 2003 American Academy of Pediatrics policy statement on pediatric radiation emergencies by summarizing newer scientific data from studies of the Chernobyl and the Fukushima Daiichi nuclear power plant events, use of improvised radiologic dispersal devices, exposures from inappropriate disposal of radiotherapy equipment, and potential health effects from residential proximity to nuclear plants. Also included are recommendations from epidemiological studies and biokinetic models to address mitigation efforts. The report includes major emphases on acute radiation syndrome, acute and long-term psychological effects, cancer risks, and other late tissue reactions after low-to-high levels of radiation exposure. Results, along with public health and clinical implications, are described from studies of the Japanese atomic bomb survivors, nuclear plant accidents (eg, Three Mile Island, Chernobyl, and Fukushima), improper disposal of radiotherapy equipment in Goiania, Brazil, and residence in proximity to nuclear plants. Measures to reduce radiation exposure in the immediate aftermath of a radiologic or nuclear disaster are described, including the diagnosis and management of external and internal contamination, use of potassium iodide, and actions in relation to breastfeeding.

The use of the Internet for children's health and the environment.

The Internet can provide a wealth of information related to the effects of environmental exposures on children's health. This article provides guidance on searching the Internet for pertinent information and discusses how to evaluate such information. It also provides an extensive list of environmental-health-related websites hosted by governmental and nongovernmental agencies, and other organizations.

Climate change and children.

Climate change is increasing the burden of climate-sensitive health determinants and outcomes worldwide. Acting through increasing temperature, changes in the hydrologic cycle, and sea level rise, climate change is projected to increase the frequency and intensity of heat events and extreme events (floods and droughts), change the geographic range and incidence of climate-sensitive vector-, food-, and waterborne diseases, and increase diseases associated with air pollution and aeroallergens. Children are particularly vulnerable to these health outcomes because of their potentially greater exposures, greater sensitivity to certain exposures, and their dependence on caregivers.

An exploration of ethical issues in research in children's health and the environment.

The consideration of ethical issues relating to pediatric environmental health is a recent phenomenon. Discussions of biomedical ethics, research on children, and environmental health research have a longer history. In the late 1990s, researchers at the Kennedy Krieger Institute in Baltimore, Maryland, undertook a study to compare the effectiveness of several methods of reducing lead risk in housing. In a preliminary finding in the case of Grimes v. Kennedy Krieger Institute, Inc., a Maryland court questioned the ethics of performing research on children when there is no prospect of direct benefit to those children and whether parents can consent to such research. This case dramatically raised the profile of ethical issues among the pediatric environmental health research community. To broaden the discussion of these issues and in response to the Kennedy-Krieger case, the Children's Environmental Health Network held a working meeting on 5 and 6 March 2004 to explore this topic. The articles in this mini-monograph were prepared by the authors as a result of the workshop and represent their opinions. This article is an introduction to the workshop and a summary of the articles to follow.

School Siting Near Industrial Chemical Facilities: Findings from the U.S. Chemical Safety Board's Investigation of the West Fertilizer Explosion.

BACKGROUND: The U.S. Chemical Safety and Hazard Investigation Board (CSB) investigated the 17 April 2013 explosion at the West Fertilizer Company (WFC) that resulted in 15 fatalities, more than 260 injuries, and damage to more than 150 buildings. Among these structures were four nearby school buildings cumulatively housing children in grades kindergarten-12, a nursing care facility, and an apartment complex. The incident occurred during the evening when school was not in session, which reduced the number of injuries. OBJECTIVES: The goal of this commentary is to illustrate the consequences of siting schools near facilities that store or use hazardous chemicals, and highlight the need for additional regulations to prevent future siting of schools near these facilities. DISCUSSION: We summarize the findings of the CSB's investigation related to the damaged school buildings and the lack of regulation surrounding the siting of schools near facilities that store hazardous chemicals. CONCLUSIONS: In light of the current lack of federal authority for oversight of land use near educational institutions, state and local governments should take a proactive role in promulgating state regulations that prohibit the siting of public receptors, such as buildings occupied by children, near facilities that store hazardous chemicals. CITATION: Tinney VA, Denton JM, Sciallo-Tyler L, Paulson JA. 2016. School siting near industrial chemical facilities: findings from the U.S. Chemical Safety Board's investigation of the West Fertilizer Explosion. Environ Health Perspect 124:1493-1496; http://dx.doi.org/10.1289/EHP132.

Nontherapeutic Use of Antimicrobial Agents in Animal Agriculture: Implications for Pediatrics.

Antimicrobial resistance is one of the most serious threats to public health globally and threatens our ability to treat infectious diseases. Antimicrobial-resistant infections are associated with increased morbidity, mortality, and health care costs. Infants and children are affected by transmission of susceptible and resistant food zoonotic pathogens through the food supply, direct contact with animals, and environmental pathways. The overuse and misuse of antimicrobial agents in veterinary and human medicine is, in large part, responsible for the emergence of antibiotic resistance. Approximately 80% of the overall tonnage of antimicrobial agents sold in the United States in 2012 was for animal use, and approximately 60% of those agents are considered important for human medicine. Most of the use involves the addition of low doses of antimicrobial agents to the feed of healthy animals over prolonged periods to promote growth and increase feed efficiency or at a range of doses to prevent disease. These nontherapeutic uses contribute to resistance and create new health dangers for humans. This report describes how antimicrobial agents are used in animal agriculture, reviews the mechanisms of how such use contributes to development of resistance, and discusses US and global initiatives to curb the use of antimicrobial agents in agriculture.

Iodine deficiency, pollutant chemicals, and the thyroid: new information on an old problem.

Many women of reproductive age in the United States are marginally iodine deficient, perhaps because the salt in processed foods is not iodized. Iodine deficiency, per se, can interfere with normal brain development in their offspring; in addition, it increases vulnerability to the effects of certain environmental pollutants, such as nitrate, thiocyanate, and perchlorate. Although pregnant and lactating women should take a supplement containing adequate iodide, only about 15% do so. Such supplements, however, may not contain enough iodide and may not be labeled accurately. The American Thyroid Association recommends that pregnant and lactating women take a supplement with adequate iodide. The American Academy of Pediatrics recommends that pregnant and lactating women also avoid exposure to excess nitrate, which would usually occur from contaminated well water, and thiocyanate, which is in cigarette smoke. Perchlorate is currently a candidate for regulation as a water pollutant. The Environmental Protection Agency should proceed with appropriate regulation, and the Food and Drug Administration should address the mislabeling of the iodine content of prenatal/lactation supplements.

Clinical services in environmental pediatrics.

Pediatric healthcare providers are confronted with environmental health problems frequently: the child with asthma exacerbated by the odor of paint in school or mouse antigen at home, the family who wants to know the risks and benefits of using different types of sunblock, or the community that asks the provider for advice on the potential health impacts of building the new elementary school next to the on-ramp to the interstate highway. Pediatric providers have not been well trained to deal with these questions in medical or nursing schools, residency training, or continuing-education settings. This article provides guidance on history taking, the physical examination, laboratory evaluations of patients and the environment, and making an assessment about and managing environmental health problems. Pediatric Environmental Health Specialty Units are discussed as a source of consultation and referral. The identification and utilization of evidence-based resources are stressed and clinicians are cautioned about non-evidence-based assessments such as clinical ecology and hair analysis and non-evidence-based management strategies such as chelation for autism.