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«CHILDREN ARE NOT LITTLE ADULTS Children's Health and the Environment WHO Training Package for the Health Sector World Health Organization ...»

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TRAINING FOR THE HEALTH SECTOR

[Date …Place …Event…Sponsor…Organizer]

Event… Sponsor…

CHILDREN ARE NOT LITTLE ADULTS

Children's Health and the Environment

WHO Training Package for the Health Sector

World Health Organization

www.who.int/ceh

July 2008 version

NOTE TO USER: Please add details of the date, time, place and sponsorship of the

meeting for which you are using this presentation in the space indicated.

NOTE TO USER: This is a large set of slides from which the presenter should select the most relevant ones to use in a specific presentation. These slides cover many facets of the problem. Present only those slides that apply most directly to the local situation in the region.

Children are not little adults

CHILDREN NEED HEALTHY ENVIRONMENTS

Health is more than absence of illness Children need healthy environments in which to grow and develop, play and learn Adults must ensure that children are protected from environmental threats Now and for generations to come!

All children deserve the right to grow up in a healthy environment where they can reach their full potential as citizens of the world. Sustainable development has at its core healthy children. Health is much more than mere absence of illness. It is the responsibility of today’s adults to identify hazards and conditions that impair children’s ability to grow and mature safely and in good health.

Health is more than absence of illness Children need healthy environments in which to grow and develop, play and learn Their environments are complex, multiple and changing.

Adults must ensure that children are protected from:

•exposures to toxic chemicals, physical injury and infections;

•poverty and malnutrition; and

•child labour.

Now and for generations to come!

NOTE TO USER: Although the term "children" is used to cover all age-groups from birth to age 19, strict WHO terminology refers to "newborns" (1 to 28 days), "infants" (up to 12 months), "children" (from 1 up to 10 years), "adolescents" (10 to 19 years).

Please note that UNICEF and other organizations may use different age groupings (UNICEF considers children as being up to 18 years old).

Ref:

•Children in the New Millennium; Environmental Impact on Health. UNEP/UNICEF/WHO, 2002 (www.who.int/water_sanitation_health/hygiene/settings/millennium/en/).

Children are not little adults

LEARNING OBJECTIVES

AFTER THIS PRESENTATION, INDIVIDUALS WILL BE ABLE TO:

List ways why risks to children from environmental hazards are different from those for adults

–  –  –

After this talk, we hope that you will be able to satisfy these four learning objectives:

• Be able to list ways in which risks to children from environmental hazards are different from those for adults.

• Be able to illustrate children’s increased and unique vulnerabilities using real-world

examples of environmental threats:

– biological;

– physical; and – chemical.

• Understand that the relationship between children and their environment begins before conception and continues throughout development.

• Propose remedial and preventive actions.

Refs:

•ATSDR Case Study on Pediatric Environmental Health, 2002 (www.atsdr.cdc.gov/HEC/CSEM/pediatric/index.html)

•Children's Health and the Environment – A global perspective. A resource guide for the health sector, WHO, 2004.

•American Academy of Pediatrics Committee on Environmental Health. Pediatric Environmental Health, 2nd ed. Etzel RA, Ed. Elk Grove Village, IL: American Academy of Pediatrics, 2003.

Children are not little adults

–  –  –

Giotto, National Gallery, Washington DC Raphael, National Gallery of Art, Washington, DC Until about 500–600 years ago, artists in Western traditions represented children as miniaturized adults just as we see in this 13th century icon. (See the painting on the left side of this slide.) Until about 50–60 years ago, doctors following the standard medical practices of the industrialized countries understood paediatric exposures as simple extrapolations from adult occupational exposures.

On the right side of the slide you can see how artists of the Renaissance painted children.

By the Renaissance artists realized that children were not simply miniaturized adults: they have big heads, long trunks and short limbs, as seen in this "Madonna and Child" by Raphael. (right side) NOTE TO USER: Use images that are regionally or culturally appropriate for illustrating the inaccuracy of thinking of children’s environmental risks simply as scaled down adult risk.

Images: National Gallery of Art, Smithsonian Institute, Washington, DC.

Children are not little adults

–  –  –

Raphael, National Gallery of Art, Washington, DC We now recognize that children, including the embryo, fetus, infant and all life stages until the completion of adolescence, are often at a different and increased risk from environmental hazards from that of adults, for reasons that can be divided into four major categories.





1. Children often have different, and sometimes unique, exposures to environmental hazards from those of adults.

2. Due to their dynamic developmental physiology children are often subjected to higher exposures to pollutants found in air, water and food. These exposures may be handled quite differently by an immature set of systems to the way they are dealt with in adults.

Furthermore, the developmental component of a child’s physiology is changing: maturing, differentiating and growing in phases known as "developmental windows". These "critical windows of vulnerability" have no parallel in adult physiology and create unique risks for children exposed to hazards that can alter normal function and structure.

3. Children have a longer life expectancy. Therefore they have longer to manifest a disease with a long latency period, and longer to live with toxic damage.

4. Finally, children are politically powerless; they are defenceless. With no political standing of their own, they must rely on adults to protect them from toxic environmental agents. Each of these points is illustrated in more detail in the following slides.

NOTE TO USER: Use images that are regionally or culturally appropriate for illustrating the inaccuracy of thinking of children’s environmental risks simply as scaled down adult risk.

Image: National Gallery of Art, Smithsonian Institute, Washington, DC.

Children are not little adults

–  –  –

Children have unique exposure pathways. They can be exposed in utero to toxic environmental agents that cross the placenta. Such exposures can be chemical (pollutants and pharmaceuticals), physical agents (radiation, heat) and biological (viral, parasitic). They can also be exposed, after birth, to pollutants that pass into their mother’s milk. Neither of these routes of exposure occur in adults or older children.

Children also have pathways of exposure that differ from those of adults due to their size and developmental stage. For example, young children engage in normal exploratory behaviours including hand-to-mouth and object-to-mouth behaviours, and non-nutritive ingestion which may dramatically increase exposure over that in adults.

Children’s physical differences also cause them to reside in a different location in the world, i.e. closer to the ground. Pollutants such as mercury, solvents, pesticides are concentrated in their breathing zone and deliberate applications of pesticides and cleaning solutions make them more readily accessible to small children. Because they are small, they have a high surface area to volume ratio and can have dramatically higher absorption through dermal contact than adults.

And, they may have much more limited ability to understand and move out of danger, both from toxic agents and dangerous situations which could result in injury. This characteristic is obvious in the pre-ambulatory phase, but persists through exploratory toddler behaviour and even into the high-risk behaviours seen in adolescence.

Children are not little adults

–  –  –

Until the disasters of phocomelia caused by thalidomide and clear cell carcinoma caused by diethylstilbesterol, it was widely believed that the placenta formed an impregnable, protective barrier between the mother and the child. Now we know that this is far from true. Many pharmaceuticals cross the placenta as do many pollutants. In addition, physical environmental hazards such as radiation and heat can harm a growing fetus. The issue of environmental health of children begins with the parents, and concerns about new exposures begin in utero.

Refs:

•Brent RL. Environmental causes of human congenital malformations: The pediatrician’s role in dealing with these complex clinical problems caused by a multiplicity of environmental and genetic factors. Pediatrics, 2004, 113:957.

•Walkowiak J et al. Environmental exposure to polychlorinated biphenyls and quality of the home environment: effects on psychodevelopment in early childhood. Lancet, 2001, 358:1602.

There is uncertainty whether environmental levels of exposure to polychlorinated biphenyls (PCBs) adversely affect mental and motor development in early childhood. We aimed to establish whether such an effect is of only prenatal or additional postnatal origin, and if a favourable home environment can counteract this effect. Methods: Between 1993 and 1995 we recruited 171 healthy mother–infant pairs and prospectively measured psychodevelopment in newborn infants aged 7, 18, 30 and 42 months. We estimated prenatal and perinatal PCB exposure of newborn babies in cord blood and maternal milk. At 42 months we measured postnatal PCB concentrations in serum. At 18 months the quality of the home environment was assessed using the Home Observation for Measurement of the Environment scale. Mental and psychomotor development of the children were assessed using the Bayley Scales of Infant Development until 30 months and the Kaufman Assessment Battery for Children at 42 months. Findings: Negative associations between milk PCB and mental/motor development were reported at all ages, becoming significant from 30 months onwards. Over 30 months, for a PCB increase from 173 (5th percentile) to 679 ng/g lipids in milk (95th percentile) there was a decrease of 8.3 points (95% CI -16.5 to 0.0) in the Bayley Scales of Infant Development mental scores, and a 9.1 point decrease (95% CI -17.2 to -1.02) in the Bayley Scales of Infant Development motor scores. There was also a negative effect of postnatal PCB exposure via breastfeeding at 42 months. Home environment had a positive effect from 30 months onwards (Bayley Scales of Infant Development mental score increase of 9.4 points [95% CI 2.2–16.7]). Interpretation: Prenatal PCB exposure at current European background levels inhibits, and a favourable home environment supports, mental and motor development until 42 months of age. PCB exposure also has an effect postnatally.

Image from www.ehponline.org/docs/2004/112-6/EHP112pa371PDF – Environmental Health Perspectives Children are not little adults

–  –  –

Breast milk is another unique source of exposure for very small children. It is clear that many environmental chemicals pass into breast milk, particularly lipophilic chemicals. Morbidity from such exposures is rare and is associated with unusual high-exposure events during which the mothers are also ill. Consequently, fear of chemical exposures should not cause a healthy mother to cease breastfeeding. For example, it is known that mercury, PCBs, lead and other POPs are present in human breast milk, but this route of exposure has not been shown to be damaging in the absence of maternal illness. Furthermore, the milk of other mammals, such as cows, often used as the basis for infant formula, is also subject to environmental contamination, and may contain higher levels of some pollutants than human milk. The condition of human milk is thus an important indication of the level of environmental contamination in the world the infant is entering, but breast milk should still be the food of first choice for any infant of a healthy mother.

NOTE TO USER: replace with image of nursing mother appropriate to the region/country.

Ref:

•Pronczuk J et al. Global perspectives in breast milk contamination: Infectious and toxic hazards. Environ Health Perspect, 2002, 110:A349.



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