Joel A. Forman

Policy statement - Tobacco use: A pediatric disease

Tobacco use and secondhand tobacco-smoke (SHS) exposure are major national and international health concerns. Pediatricians and other clinicians who care for children are uniquely positioned to assist patients and families with tobacco-use prevention and treatment. Understanding the nature and extent of tobacco use and SHS exposure is an essential first step toward the goal of eliminating tobacco use and its consequences in the pediatric population. The next steps include counseling patients and family members to avoid SHS exposures or cease tobacco use; advocacy for policies that protect children from SHS exposure; and elimination of tobacco use in the media, public places, and homes. Three overarching principles of this policy can be identified: (1) there is no safe way to use tobacco; (2) there is no safe level or duration of exposure to SHS; and (3) the financial and political power of individuals, organizations, and government should be used to support tobacco control. Pediatricians are advised not to smoke or use tobacco; to make their homes, cars, and workplaces tobacco free; to consider tobacco control when making personal and professional decisions; to support and advocate for comprehensive tobacco control; and to advise parents and patients not to start using tobacco or to quit if they are already using tobacco. Prohibiting both tobacco advertising and the use of tobacco products in the media is recommended. Recommendations for eliminating SHS exposure and reducing tobacco use include attaining universal (1) smoke-free home, car, school, work, and play environments, both inside and outside, (2) treatment of tobacco use and dependence through employer, insurance, state, and federal supports, (3) implementation and enforcement of evidence-based tobacco-control measures in local, state, national, and international jurisdictions, and (4) financial and systems support for training in and research of effective ways to prevent and treat tobacco use and SHS exposure. Pediatricians, their staff and colleagues, and the American Academy of Pediatrics have key responsibilities in tobacco control to promote the health of children, adolescents, and young adults.

Global climate change and children's health

There is a broad scientific consensus that the global climate is warming, the process is accelerating, and that human activities are very likely (>90% probability) the main cause. This warming will have effects on ecosystems and human health, many of them adverse. Children will experience both the direct and indirect effects of climate change. Actions taken by individuals, communities, businesses, and governments will affect the magnitude and rate of global climate change and resultant health impacts. This technical report reviews the nature of the global problem and anticipated health effects on children and supports the recommendations in the accompanying policy statement on climate change and childrens health.

Organic Foods: Health and Environmental Advantages and Disadvantages

The US market for organic foods has grown from

Grand Rounds: Nephrotoxicity in a Young Child Exposed to Uranium from Contaminated Well Water

3.5 billion in 1996 to

Drinking water from private wells and risks to children.

28.6 billion in 2010, according to the Organic Trade Association. Organic products are now sold in specialty stores and conventional supermarkets. Organic products contain numerous marketing claims and terms, only some of which are standardized and regulated. In terms of health advantages, organic diets have been convincingly demonstrated to expose consumers to fewer pesticides associated with human disease. Organic farming has been demonstrated to have less environmental impact than conventional approaches. However, current evidence does not support any meaningful nutritional benefits or deficits from eating organic compared with conventionally grown foods, and there are no well-powered human studies that directly demonstrate health benefits or disease protection as a result of consuming an organic diet. Studies also have not demonstrated any detrimental or disease-promoting effects from an organic diet. Although organic foods regularly command a significant price premium, well-designed farming studies demonstrate that costs can be competitive and yields comparable to those of conventional farming techniques. Pediatricians should incorporate this evidence when discussing the health and environmental impact of organic foods and organic farming while continuing to encourage all patients and their families to attain optimal nutrition and dietary variety consistent with the US Department of Agriculture’s MyPlate recommendations. This clinical report reviews the health and environmental issues related to organic food production and consumption. It defines the term “organic,” reviews organic food-labeling standards, describes organic and conventional farming practices, and explores the cost and environmental implications of organic production techniques. It examines the evidence available on nutritional quality and production contaminants in conventionally produced and organic foods. Finally, this report provides guidance for pediatricians to assist them in advising their patients regarding organic and conventionally produced food choices.

Chemical-biological terrorism and its impact on children.

Context Private wells that tap groundwater are largely exempt from federal drinking-water regulations, and in most states well water is not subject to much of the mandatory testing required of public water systems. Families that rely on private wells are thus at risk of exposure to a variety of unmeasured contaminants. Case Presentation A family of seven—two adults and five children—residing in rural northwestern Connecticut discovered elevated concentrations of uranium in their drinking water, with levels measured at 866 and 1,160 μg/L, values well above the U.S. Environmental Protection Agency maximum contaminant level for uranium in public water supplies of 30 μg/L. The uranium was of natural origin, and the source of exposure was found to be a 500-foot well that tapped groundwater from the Brookfield Gneiss, a geologic formation known to contain uranium. Other nearby wells also had elevated uranium, arsenic, and radon levels, though concentrations varied widely. At least one 24-hr urine uranium level was elevated (> 1 μg/24 hr) in six of seven family members (range, 1.1–2.5 μg/24 hr). To assess possible renal injury, we measured urinary beta-2-microglobulin. Levels were elevated (> 120 μg/L) in five of seven family members, but after correction for creatine excretion, the beta-2-microglobulin excretion rate remained elevated (> 40 μg/mmol creatinine) only in the youngest child, a 3-year-old with a corrected level of 90 μg/mmol creatinine. Three months after cessation of well water consumption, this child’s corrected beta-2-microglobulin level had fallen to 52 μg/mmol creatinine. Significance This case underscores the hazards of consuming groundwater from private wells. It documents the potential for significant residential exposure to naturally occurring uranium in well water. It highlights the special sensitivity of young children to residential environmental exposures, a reflection of the large amount of time they spend in their homes, the developmental immaturity of their kidneys and other organ systems, and the large volume of water they consume relative to body mass.

Policy statement - Ultraviolet radiation: A hazard to children and adolescents

Drinking water for approximately one sixth of US households is obtained from private wells. These wells can become contaminated by pollutant chemicals or pathogenic organisms, leading to significant illness. Although the US Environmental Protection Agency and all states offer guidance for construction, maintenance, and testing of private wells, there is little regulation, and with few exceptions, well owners are responsible for their own wells. Children may also drink well water at child care or when traveling. Illness resulting from childrens ingestion of contaminated water can be severe. This report reviews relevant aspects of groundwater and wells; describes the common chemical and microbiologic contaminants; gives an algorithm with recommendations for inspection, testing, and remediation for wells providing drinking water for children; reviews the definitions and uses of various bottled waters; provides current estimates of costs for well testing; and provides federal, national, state, and, where appropriate, tribal contacts for more information.

The Environment in Pediatric Practice: A Study of New York Pediatricians’ Attitudes, Beliefs, and Practices towards Children’s Environmental Health

Children remain potential victims of chemical or biological terrorism. In recent years, children have even been specific targets of terrorist acts. Consequently, it is necessary to address the needs that children would face after a terrorist incident. A broad range of public health initiatives have occurred since September 11, 2001. Although the needs of children have been addressed in many of them, in many cases, these initiatives have been inadequate in ensuring the protection of children. In addition, public health and health care system preparedness for terrorism has been broadened to the so-called all-hazards approach, in which response plans for terrorism are blended with plans for a public health or health care system response to unintentional disasters (eg, natural events such as earthquakes or pandemic flu or manmade catastrophes such as a hazardous-materials spill). In response to new principles and programs that have appeared over the last 5 years, this policy statement provides an update of the 2000 policy statement. The roles of both the pediatrician and public health agencies continue to be emphasized; only a coordinated effort by pediatricians and public health can ensure that the needs of children, including emergency protocols in schools or child care centers, decontamination protocols, and mental health interventions, will be successful.

Impact of september 11 World Trade Center disaster on children and pregnant women

Ultraviolet radiation (UVR) causes the 3 major forms of skin cancer: basal cell carcinoma; squamous cell carcinoma; and cutaneous malignant melanoma. Public awareness of the risk is not optimal, overall compliance with sun protection is inconsistent, and melanoma rates continue to rise. The risk of skin cancer increases when people overexpose themselves to sun and intentionally expose themselves to artificial sources of UVR. Yet, people continue to sunburn, and teenagers and adults alike remain frequent visitors to tanning parlors. Pediatricians should provide advice about UVR exposure during health-supervision visits and at other relevant times. Advice includes avoiding sunburning, wearing clothing and hats, timing activities (when possible) before or after periods of peak sun exposure, wearing protective sunglasses, and applying and reapplying sunscreen. Advice should be framed in the context of promoting outdoor physical activity. Adolescents should be strongly discouraged from visiting tanning parlors. Sun exposure and vitamin D status are intertwined. Cutaneous vitamin D production requires sunlight exposure, and many factors, such as skin pigmentation, season, and time of day, complicate efficiency of cutaneous vitamin D production that results from sun exposure. Adequate vitamin D is needed for bone health. Accumulating information suggests a beneficial influence of vitamin D on many health conditions. Although vitamin D is available through the diet, supplements, and incidental sun exposure, many children have low vitamin D concentrations. Ensuring vitamin D adequacy while promoting sun-protection strategies will require renewed attention to childrens use of dietary and supplemental vitamin D.

The Ambulatory Pediatric Association Fellowship in Pediatric Environmental Health: A 5-Year Assessment

Chronic diseases of environmental origin are a significant and increasing public health problem among the children of New York State, yet few resources exist to address this growing burden. To assess New York State pediatricians self-perceived competency in dealing with common environmental exposures and diseases of environmental origin in children, we assessed their attitudes and beliefs about the role of the environment in children’s health. A four-page survey was sent to 1,500 randomly selected members of the New York State American Academy of Pediatrics in February 2004. We obtained a 20.3% response rate after one follow-up mailing; respondents and nonrespondents did not differ in years of licensure or county of residence. Respondents agreed that the role of environment in children’s health is significant (mean 4.44 ± 0.72 on 1–5 Likert scale). They voiced high self-efficacy in dealing with lead exposure (mean 4.16–4.24 ± 0.90–1.05), but their confidence in their skills for addressing pesticides, mercury and mold was much lower (means 2.51–3.21 ± 0.90–1.23; p < 0.001). About 93.8% would send patients to a clinic “where pediatricians could refer patients for clinical evaluation and treatment of their environmental health concerns.” These findings indicate that New York pediatricians agree that children are suffering preventable illnesses of environmental origin but feel ill-equipped to educate families about common exposures. Significant demand exists for specialized centers of excellence that can evaluate environmental health concerns, and for educational opportunities.