Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

In seems strange that in an age when we are saving so many infants and children by prophylaxis against disease, antibiotics, prenatal diagnosis, premature care, and amazing surgical methods, we are now exposing many of them to environmental hazards, pollution, and iatrogenic damage.

Those of us who have practiced pediatrics during the past 50 years bitterly learned many of our lessons firsthand. I'm sure that everyone of us can think back to one or more of such incidents in which we were personally involved. It wasn't due to lack of adequate medical training or lack of up-to-date medical knowledge or lack of the best facilities.

I, personally, am still troubled by the memory of one such case. The baby girl developed a severe upper respiratory infection with fever a few days after birth and was transferred to our pediatric service. It was in the early 1950s, and a combined antibiotic of penicillin and streptomycin (widely used at that time) was advised by our authority on antibiotics. The baby recovered from the infection - but as she grew older I soon realized that I was caring for a beautiful little deaf child.

It wasn't until some time later that we fully realized that the glomerular filtration in the neonate was only 30 to 40 per cent of the adult filtration and the tubular secretion 20 to 30 per cent of the adult secretion, both based on surface area. We had concentrated the streptomycin in the infant's blood.

We are living today in the period during which the greatest scientific advances in the world's history have been made. But we are also living in the iatrogenic age and the age of environmental hazards and pollution. And, without much question, we pediatricians are the most involved of all practitioners in the problems these new hazards cause.

It is of extreme importance, then, that we begin to safeguard our children before they are born. They must be protected during the fetal period from teratogenic and carcinogenic influences - whether these be external, as in the case of x-rays; transplacental, as in the case of thalidomide; or such long-dormant substances as DES (diethylstilbestrol), which, when given to pregnant women, can - years later - produce adenocarcinomas in the vaginas of their daughters when they enter adolescence.

And these are not the only prenatal hazards. Today pediatricians must be aware that certain environmental conditions and pollutants can damage the fetus or even cause fetal death. Pesticides, the organic mercurials, and the nitrates are such materials, to mention only a few.

The industrial waste poiychlorinated biphenyl (PCB) has recently received considerable attention in the news media, for it has been found in the water and food supply in various parts of the country. The PCBs (for there are a number of different members of this chemical group) permeate the water and food supply, enter the human body, and may be transmitted through the placenta to the fetus and, later, through the nursing mother's milk to her infant. These compounds are teratogenic and carcinogenic in experimental animals. Dr. Laurence Finberg, in his article in this issue of PEDIATRIC ANNALS, describes the damaging effects when accidentally high concentrations of PCB contaminated a supply of rice oil in Japan. We do not know the final effects of PCB on children, since the compound remains in the body for years and possibly decades.

Just as we pediatricians are in the forefront of those active in the prevention of disease through prophylaxis, so should we be at the forefront of the groups who are making efforts to prevent serious damage, malformations, and…

In seems strange that in an age when we are saving so many infants and children by prophylaxis against disease, antibiotics, prenatal diagnosis, premature care, and amazing surgical methods, we are now exposing many of them to environmental hazards, pollution, and iatrogenic damage.

Those of us who have practiced pediatrics during the past 50 years bitterly learned many of our lessons firsthand. I'm sure that everyone of us can think back to one or more of such incidents in which we were personally involved. It wasn't due to lack of adequate medical training or lack of up-to-date medical knowledge or lack of the best facilities.

I, personally, am still troubled by the memory of one such case. The baby girl developed a severe upper respiratory infection with fever a few days after birth and was transferred to our pediatric service. It was in the early 1950s, and a combined antibiotic of penicillin and streptomycin (widely used at that time) was advised by our authority on antibiotics. The baby recovered from the infection - but as she grew older I soon realized that I was caring for a beautiful little deaf child.

It wasn't until some time later that we fully realized that the glomerular filtration in the neonate was only 30 to 40 per cent of the adult filtration and the tubular secretion 20 to 30 per cent of the adult secretion, both based on surface area. We had concentrated the streptomycin in the infant's blood.

We are living today in the period during which the greatest scientific advances in the world's history have been made. But we are also living in the iatrogenic age and the age of environmental hazards and pollution. And, without much question, we pediatricians are the most involved of all practitioners in the problems these new hazards cause.

It is of extreme importance, then, that we begin to safeguard our children before they are born. They must be protected during the fetal period from teratogenic and carcinogenic influences - whether these be external, as in the case of x-rays; transplacental, as in the case of thalidomide; or such long-dormant substances as DES (diethylstilbestrol), which, when given to pregnant women, can - years later - produce adenocarcinomas in the vaginas of their daughters when they enter adolescence.

And these are not the only prenatal hazards. Today pediatricians must be aware that certain environmental conditions and pollutants can damage the fetus or even cause fetal death. Pesticides, the organic mercurials, and the nitrates are such materials, to mention only a few.

The industrial waste poiychlorinated biphenyl (PCB) has recently received considerable attention in the news media, for it has been found in the water and food supply in various parts of the country. The PCBs (for there are a number of different members of this chemical group) permeate the water and food supply, enter the human body, and may be transmitted through the placenta to the fetus and, later, through the nursing mother's milk to her infant. These compounds are teratogenic and carcinogenic in experimental animals. Dr. Laurence Finberg, in his article in this issue of PEDIATRIC ANNALS, describes the damaging effects when accidentally high concentrations of PCB contaminated a supply of rice oil in Japan. We do not know the final effects of PCB on children, since the compound remains in the body for years and possibly decades.

Just as we pediatricians are in the forefront of those active in the prevention of disease through prophylaxis, so should we be at the forefront of the groups who are making efforts to prevent serious damage, malformations, and the possibility of future cancer among the children of the world. It is important that we do what we can to prevent contamination rather than merely being the caretakers of damaged children. Sometimes, for example, radioactive substances enter our environment as a result of an atomic explosion or from an accident at a nuclear plant. I do not mean to imply that we should necessarily oppose the development of nuclear energy. But we should insist that the greatest precautions be observed in the operation of nuclear plants.

This is the first of two issues of PEDIATRIC ANNALS to be devoted to environmental hazards affecting infants and children. Both are under the guest editorship of Dr. Jay M. Arena, whose classic volume on poisoning is known to all pediatricians. Dr. Arena is at present Professor of Pediatrics and Director of the Poison Control Center at Duke University.

The opening paper in this symposium has been prepared by Dr. Arena himself and deals with the effects of drugs and chemicals on the mother and her child. This is an important and valuable article. Here the author answers many of our questions concerning which drugs taken by a pregnant woman are likely to be teratogenic. What should a mother do if, for instance, she is forced to take oral anticoagulants, which in many instances pass through the placenta and cause fetal malformations? The same question can be asked when women are taking anticonvulsants or cortisone preparations.

But there are other effects of drugs on the fetus. So many times pregnant women ask the pediatrician whether they can safely take such "simple preparations" as aspirin or some antibiotic for an infection. Most of us prefer that a pregnant woman avoid all drugs during pregnancy, certainly during the first and third trimesters. But what if she has a severe infection and must take an antibiotic?

Dr. Arena not only discusses these problems but presents specific tables where he lists the drugs that, if taken by pregnant women, may be teratogenic or carcinogenic, cause fetal death, or affect the newborn in other ways.

The last portion of this informative article discusses the danger to infants and children of absorbing through ingestion large amounts of contaminants in food and water. These contaminants - which may be found in grain, fish, fowl, and other foods - may be very damaging to infants and children, and some of the most dangerous may cross the placenta.

The second article, "Environmental Hazards in the Newborn Nursery," is presented by Dr. Audrey Brown and Dr. Leonard Glass, of the State University of New York, Downstate Medical Center, Brooklyn. Both are Professors of Pediatrics; Dr. Brown is associate chairman of the department, and her coauthor is director of newborn services. It should be mentioned that Dr. Glass is coauthor of the volume Perinatal Medicine. This paper describes the neonatal environment in the nursery and discusses a number of potential hazards that could exist and how they can be prevented or eliminated. Among the subjects covered are thermal and electrical hazards and the dangers of infection. The effects of phototherapy, both potential and actual, are also presented. This is a method of treatment that has been questioned since it was first introduced, about nine or 10 years ago.

The authors also consider the problem of excessive noise in the nursery (the most constant noise being caused by the motors of incubators) and how it may affect the hearing of newborn infants. Among the other hazards that could affect infants in the nurseries are toxic substances, such as insecticides and compounds used in the sterilization of linens, nursery bottles, and other equipment. This article contains many interesting facts, some of which are often overlooked in newborn nurseries.

The third contribution, "Toxic Substances in the Food Supply of Infants and Children," was written by Dr. Laurence Finberg, Professor of Pediatrics and chairman of the department of the Albeit Einstein College of Medicine, New York City. Essentially, Dr. Finberg deals with three aspects of this problem: the natural toxins (those formed by decaying food and by bacteria or bacterial toxins), food additives (some of which have been placed there to prevent spoilage), and contaminants placed in the environment by man. In discussing food additives, he also mentions some of the problems caused when deletions are made in some food products - for example, the lack of needed salt in some soybeanformula preparations. (For this omission, two such products are receiving considerable criticism on television and in other media at the moment of this writing.)

Dr. Finberg discusses at some length the problems caused by contaminants placed in the environment by man. The potential danger of methyl mercury is especially frightening, for once absorbed into the system it remains there; it can be removed by only two means (both in the female), through the placenta and through breast-feeding.

The PCBs and PBBs are also discussed, and the author reviews results of accidents that have occurred when large amounts of these substances have inadvertently been ingested by people. Once again, the need is emphasized for pediatricians to publicize these dangers and be at the forefront in efforts to ban such contamination.

The final contribution in this present symposium deals with the epidemiology of cancer. It is authored by Dr. Robert W. Miller, chief of the Epidemiology Branch of the National Cancer Institute, Bèthesda, Md. After a general discussion of etiology of cancer as related to age, ethnic differences, sex, and size of a child, Dr. Miller discusses case histories as an important source in discovering the etiology, as in the example of DES.

Chemical carcinogenesis is also largely reported from occupational studies. Retrospective studies, as in cases of leukemia, and family studies may also indicate causes. The prenatal origins of some cancers are also discussed.

Our second issue on environmental hazards will appear early next year.

10.3928/0090-4481-19791201-03

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